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 It won't take very long to find out whose opinion you actually value and whose you find outdated or downright wrong.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

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.

FAIL

So far, I have been pretty lucky with patient’s actually showing up on time for appointments. Most of them have been making all payments as well, so yea – good fortune. I have had a few patients’ cancel their appointments but they have always done so at least a day in advance. True it isn’t always enough time for me to fill the spot, but at least I have a chance.

So today, of all days I had my first patient failure. This equates to the patient not showing up, not calling, and you simply can’t get a hold of them to find out why. I was going to do one of my performance exams on this patient so I am justifiably pissed. Not only did I waste my afternoon (which costs about 150 in tuition), but I have to find a new patient to do the PE on. School policy is that I can dismiss this patient because she failed the initial exam (normally we have a 2-strike policy after they have been coming for awhile).

I am at a crossroads. This patient cancelled the previous initial exam last week but called the day before. She also made her own FMX appointment and got the x-rays taken without me having to do anything. So I don’t quite understand how to take the situation.
If she doesn’t call back by tomorrow, I will most likely dismiss her as a patient. Just sucks that I was all ready to get some requirements out of the way and now am back at square one. On the plus side, I have scheduled a transfer patient for an appointment who is a veritable gold mine of directs and crowns. So I will finally get some consistent operative experience.

Funny side note:

We are required to call our pedo patients the day prior to our rotations. I have pedo on Friday..hence calling on Thursday. We don’t have to actually schedule them, we just verify that the scheduled patient still plans on coming. Well, it seems that 2 out of every three kids I get does not speak English. I don’t speak Spanish. So when I call and mom answers with: bueno, I naturally get a bit off guard. I totally half-assed my way through, and she seemed to understand. Needless to say, my classmates around the phone area were laughing their asses off. Get your jollies now people, it will happen to you to.

Cutting REAL teeth

Today was my first foray into the operative component of dentistry. It was definitely a nice change of pace from the constant stream of perio problems, dentures, and RPDs. It was the perfect starter for any newbie like myself – a very conservative prep on the distal of the left second premolar. I didn’t even need to provide anesthetic. I rarely used round burs on the plastic teeth, but that was all I used this afternoon to make a nice little slot in the side of the tooth. Got my instructor to check, and he said “looks good.” Sweet. The hard part was placing the composite. You really don’t understand what working in a wet mouth is like when you practice this stuff on plastic teeth. Composite resin requires a DRY field to work in. Placing a rubber dam is not always practical (especially when the patient lacks any posterior teeth to clamp). So I just loaded her up with gauze and the suction tip.

The placement went ‘ok.’ I had a bit of excess that I didn’t notice until after I cured everything, but my instructor showed me a few good tips on how to really take advantage of the finishing burs. I finally had her bite down on some articulating paper to check if the restoration was too high. I hear this horrible crunching sound. SHIT! Thankfully she only fractured a tiny bit of the marginal ridge off, which was the high part anyways. I just smoothed it off, checked occlusion again and sent her on her merry way.

GO ME!

Uninformed

Ok, here is my first post in a bit. I really haven’t had any reason not to post, outside of rediscovering what having a life is all about. I actually have time to do stuff…it is a crazy feeling.

That’s not to say that things can’t get stressful. In fact, I would say that school itself IS more stressful in the clinics, but you get used to it, and then you go home and drink a beer or scotch. I mean let’s consider: on the one hand, you are sitting in a lecture hall fighting to stay awake while you learn about kidney stones or something. Yea, not stressful. On the other other hand, you are running around the clinics like a chicken with its head chopped off trying to find the vitrebond, or locate a professor to help you use the facebow or do something else you vaguely remember being taught in a half-assed fashion eons ago. Yea, stressful.

In fairness though, things would be much smoother if all the damn construction wasn’t conveniently scheduled for my entrance into the clinics – again, something that would have been nice to know during interviews..cough cough. Would I have gone somewhere else? Probably not, but it still sucks.

So clinic craziness aside, things are still great. You learn a billion things a day and you feel the experience growing with each and every patient encounter. I no longer am timid when rooting around someone’s mouth. I am slowly improving my operator positioning as I learn how much easier it is when you can have the patient move their head to one side or the other (the mannequin head lacked this quality).

My major complaint as of now is that I STILL have not cut a tooth yet…seriously. I have classmates that have done tons of direct restorations, crowns, ect. I have been doing initial exams and dentures all day every day so far. All my initial patients seem to have zero caries and tons of perio issues which will require either more dentures or RPDs. However, good things are on the rise. A recent transfer patient needs about twelve, count em’, TWELVE directs. Not the crappy class V’s either. I’m talking class I’s, II’s, and III’s. The stuff we get tested on for boards. Hopefully he returns my friendly phone call for an appointment. Keeping my fingers crossed on that one.

OK, time for the gist of this post. How hard would it be to sit us down during one of our ‘comp care’ lectures and outline exactly WHAT we are expected to accomplish/turn in this semester? This course is run by so many different people that clearly don’t communicate with one another and it is impossible to get a straight answer. We have FOUR performance exams that MUST be completed before this quick 12 week semester ends. Yes they aren't part of the comp care course, but we also have no lectures for these courses..so when else are we supposed to find out? Two of these are for perio and two for restorative. Yes you can find all this information if you dig around on blackboard or ask an upperclassmen. But why can’t there be one big sheet of paper they hand out during one of numerous lectures that says: “THIS IS WHAT YOU HAVE TO DO BEFORE FALL.”
There is some random endo exam we must take in July also. What should we study? Who knows.

Ahhh but complaining feels stupid when I am still in such a good place. Yea I spent 6 hours at school this weekend doing assorted lab work and filling up my scheduler. But I even impressed myself at how easy making record bases and wax rims was this time around (first time in 6 months..must be like riding a bike). I can only pray that this technical carry-over applies to operative procedures as well.

I was going to whine more, but I see no point. This is how dental school goes, just suck it up and learn as much as you can. There are plenty of great teachers and opportunities to really develop. These last two years are what count the most towards getting off on the right foot in the real world. Real-time job training.

The D-3 Experience I

Amazing. Exhausting. Terrifying. Fun. These four words spring to mind after completing one week as a D-3 student. I have gotten home exhausted pretty much every day, I am amazed at how much experience I have gained in five days, I am terrified by how little I actually know, and I am having fun amongst it all. I love it. I may be a bit blinded by how much hatred I had for the last semester of D-2 year, which finally got our grades up this week and I did pretty awful compared to previous semesters. What sucks is that I was border line in every class - but where I would usually end up on the better side of that border, I seemed to get hosed in nearly every course this time. Key difference though, I don’t give shit. A ‘B’ is not a bad grade, and it isn’t a damning grade either towards any future aspirations (at least for someone who isn’t planning on specializing IMMEDIATELY after graduating if at all).

I am totally digressing though, this is not a post to whine about last year, it is to discuss initial impressions of my new found status as an upperclassmen. I know I will have bad days, I will be humbled, humiliated, ect., but I hope to learn a LOT. I see no other alternatives when you are practicing dentistry on real people every day. So far, I have really enjoyed it.

I was nervous Monday morning, had that same uneasy feeling you get when you are about to step into a new world – very similar to orientation. Once I got going, things just blazed by and before I knew it I was sitting at home with a beer watching TV.

So what is my schedule you ask? Here goes:

Monday:
8-10: Dental Public Health (meets 6 times, done in July)
10 – 4:30 - Clinic (lunch is designated 12:30-1:30)

Tuesday:
8-10 - Dental Ethics (meets 8 times, done in July)
10 – 4:30 - Clinic

Wednesday:
10-4:30 Clinic

Thursday:
8-9 - Pain control II
9 – 10 - Comp care IIIa lectures
10-4:30 Clinic

Friday:
8-10 - Basic Oral Surgery (but less basic than last semester)
10-4:30 Clinic

OKOK, now some of these numbers vary. Clinic time can be spent in many ways. We generally have a morning block and afternoon block of time, so we usually can’t see more than two patients a day. HOWEVER, we also have several required rotations scheduled at various times that take precedence over general clinic. Now we won’t all go through the same rotations this summer, but by the time graduation rolls around, everyone will have spent an equal amount of time in each rotation.
Generally when we have a rotation, one session occupies half of any given day and lasts a week. So when on rotation, half your time slots will not be available to schedule patients for that week.

Here is a breakdown of what I go through this summer:
Urgent Care (12 sessions) – Basically we treat the walk-in emergencies of the day. Usually end up referring to post-grad endo or OS. If we get lucky, we can do something interesting like a pulpotomy. The best part of urgent care is that you can pick up new patients with interesting cases. Most of your endodontic experience will be gained through urgent care patients. I had my first rotation this week, and picked up a new comprehensive care patient (which is great as most of my current patients refuse to call me back).

Oral Medicine (2 sessions) – We will be in here checking out oral pathologies and working on our clinical exam skills. I need to remind myself to reschedule one of these rotations as it conveniently overlaps one of my OS finals.

Radiology (5 sessions) – become cheap labor in the radiology department and take FMX and pans all morning/afternoon. I have this in 2 weeks and am glad because I need more practice.

Invisalign Training (1 day) – Get certified in invisalign in 8 hours, sounds good.

Pediatric Rotation – EVERY FRIDAY AFTERNOON FOR THE ENTIRE D-3 YEAR. Holy crap..that is a lot of pedo experience. I really hope I can learn to manage little kids by the time this is all said and done.

My only gripe is that I am missing out on the oral surgery rotation that most of my classmates seem to have. It lasts three weeks and must be completed before you can start extracting teeth without heavy supervision. Seeing as MANY urgent care patients require simple extractions, it sucks that I won’t really be able to start until I get my OS rotation (hopefully early in the fall).

All other clinic hours are meant for our patients. If a patient cancels, or you just couldn’t book anyone, you are expected to help out in urgent care, assist classmates, call patients, do lab work. You can’t just take off (although it seems like nobody would notice in the chaos that is this summer due to all the clinic shuffling). I really don’t mind doing UC when I have nothing else going on; it provides extra experience and offers the slim possibility of picking up a new patient.

Quick breakdown of courses:

Comprehensive Care IIIa – I loathe comp care. Simple as that. This class seems like it will be very similar to last semester, with a constant stream of ticky tack assignments just to bug the hell out of you. I’m not sure of the grade breakdown yet.

Dental Public Health – Haven’t had the class yet, but I doubt it will be a problem..most likely to be annoying though. 8 am still sucks for any lecture.

Dental Ethics – While this class sounds terrible, I can actually find value in it. There are plenty of really tough situations that I wouldn’t mind talking through with my classmates and faculty.

Endo Clinic I – This class is carried over a bit from last semester (I’m not exactly sure what else we do to get graded). I know if I get at least one RCT done this summer, my ‘experience’ grade will be an ‘A.’ Other than that…not sure.

Basic OMFS – very similar to last semester, some of the intstructors write absolutely dreadful multiple choice questions which pretty much makes easy tests much harder.

Pain Control II – The bad lecturer from the other OS classes is not in this one, so thank god. Hopefully the tests will actually be manageable. We get to load up each other on nitrous again at the end of the semester.

Perio Clinic I – I honestly didn’t even know this was a class until I looked up my schedule while writing this post. I assume we will be evaluated by the perio faculty for this grade.

Restorative Clinic I – Not sure how we are evaluated (performance exams most likely), but I will update when I figure it out. Hope I actually get to do some direct restorations this semester…it sure feels like all of my patients only need RPDs, Dentures, or Perio.


So that wraps up the official schedule, here are some drawbacks that will become more apparent as I get further into the year:
1.) Not enough chairs – with all the construction going on this summer (not to mention over-matriculation of international students), we are really tight on space. I am lucky if I can book a patient within a week at this point which sucks.

2.) Lack of endo – several of my peers have completed root canals already (some have done more than one). This sucks because it is pure luck if you find one through urgent care which seems to be the main avenue for RCT cases. This is also the one specialty I am interested in, so I would like to get some experience to determine if my interest stays legitimate.

3.) Lack of patients – yes I still lack a good patient pool, I know I will be getting more and more as the summer progresses, but I still have a TON of blank spaces on my calendar.

4.) D-4’s still around – I was under the impression that MOST of the D-4 students would be on rotations this summer, but it seems like they are all still around. Of course having them around is also helpful, because they can quickly offer advice/help when you most need it.

5.) Performance exams – Finding enough patients to practice, and then finding a good one to get graded on for any procedure simply sucks. I still am unaware of our actual requirements this summer, but I know it will be stressful.

6.) Not knowing what the hell you are doing – yes, believe it or not, the two years of pre-clinical training really can’t prepare you for live patients. It is frightening to be responsible for someone’s well-being when you feel so naïve and overwhelmed. All of the upperclassmen claim that it takes some time, but we will eventually feel pretty confident doing many different procedures. I hope so!

7.) Unclear expectations/goals – I really don’t know how we are evaluated, or what we are expected to complete.
Enough bitching! Most of that is pre-emptive bitching anyways because I haven’t had enough experience yet. Bottom line is that I am quite happy with where I’m at right now. I look forward to getting the ball rolling with my patients and actually improving their quality of life. I haven’t even thought about that yet.

Now I’m off to enjoy a three-day weekend. The nice weather has finally arrived!

Period Of Adjustment

Two days into life as a third year dental student and the differences can easily be identified. First off, we don't have that much class, simple as that. I had monday morning off and I have tomorrow morning off (this means I don't have to be at school until 9:30 or 10:00 depending on if I have a patient or am on rotation). That extra 1.5 hours of sleep already kicks sooo much ass. Two of my courses this semester also end in early July, meaning I will only have early class on Thursdays and Fridays. I will break down the schedule in a week or so.

So what am I doing then? Working my ass off in the clinic trying to adjust and get used to everything. While our early clinic exposure did help during the D-2 year, it is a completely different animal when you are in there all the time, expected to be doing something, and doing that something well. One major flaw I already see in myself is lack of speed. I am far to slow and cannot adjust to changes in appointment plan fast enough. For example, I planned on getting 1/2 my initial exam done on my patient this afternoon. Instead, he spent 1.5 hours getting full mouth radiographs taken, then I essentially spent the rest of the time trying to deal with all his health problems that were clearly not under control. Blood pressure of 180/110 is NOT good. Blood glucose of 241 mg/dL is also NOT good for a 'controlled' diabetic. Had to write up a medical consult, and then before I knew it, I was already 45 minutes past the time we are supposed to be DONE!! So all my chart entries are unapproved because our instructor pretty much jetted after he signed the med consult. So now I have to hunt him down tomorrow to get all my unapproved entries swiped through.

I got home around 6pm, tired and drained. But instead of studying pharm..or reading endo...or writing a bussiness report...I opened a beer, grilled a few hot dogs and watched tv.

Now THERE is the big difference.

I know things will change. For one, I won't be able to drink a beer and do nothing every night I get home. There will be projects and lab work to do, and the few courses I have will require a bit of out-o-class time, but I know it will pale in comparison to the first two years. On the plus side too, I doubt I will be stuck in the school an hour late doing simple procedures after a few months grinding it out in the clinics. I am bound to get better by sheer repitition. I am aware of my shortcomings, which is a great step in learning to resolve them.

Everyone says D-3 year is the best. I can see this being true - especially after I adjust and get better at things that I know are simple, improve my communication with patients, and improve my general knowledge of common clinical problems such as what to prescribe for so and so or how drug X may interfere with treatment option Y...and so forth.

My only gripe is in regards to the lack of chairs. This would not normally be a problem at this school, but they decided to refurbish the pediatric and ortho clinics this summer. So those two clinics have been crammed in with the undergrad clinics and we are all shuffled around right now. That in itself isn't horrible, but what really steams me is the fact that the admissions committee cannot do simple math. They over-accepted on international students in the last cycle and they don't have enough room in the pre-clinic for the newcomers. This means that 8 of our clinic chairs are getting sucked up for pre-clinical courses. Guess what clinic they are in? Mine of course. So there are only 10 restorative chairs on tue and wed for my clinic now. Hmmm..there are 11 D-3s, 3 IDDP-2s, and 11 D-4s. This is going to work out great right? Ok ok..several of the D-4s will be out on rotation and we never ALL need restorative chairs (often need perio and sometimes endo)...but still. This is how I feel.

Well I will save further ramblings for my formal D-3 experience post. Just wanted to let all know that things have started and I am learning to adjust. I hope to be fully assimilated by the end of this summer.

Back to total relaxing and sleeping in until 9am. SWEET.