Day 16

Memorial Day :)

I went home to see my husband, family, and my parents-in-law.

Was an amazing break and I enjoyed it very much!

Day 15

Today I assisted with a complex surgical extractions and bilateral tori removal by Dr. Fleenor. Assisted with another full-mouth extractions as it really helps me see everything close up and personal.

Dr. Fleenor uses continuous sutures and they look something like this but much better ;)

Then I extracted teeth #6, 7, 8, 9 and 10. Patient had very dense bone and I have learned to use the rongeur to extract fractured roots. I also delivered a set of dentures. Patient was very satisfied and said they fit much better than his old set of dentures.

Day 14

Placed amalgam fillings on #18F and 18O. Then saw another patient who had a fractured #15DOL and restored with amalgam.

Extracted six teeth- 2, 4, 5, 15, 28 and 29 and sutured the sites where primary closer was possible.

Had another patient who had 2 large cervical caries on #22F and 27MF and his partial depends on these two teeth so he was hoping to have them restored. We discussed the benefits of amalgam vs. composite and he said he wants amalgam to keep his teeth. Dr. Schmidt checked my preps and helped me establish better retention by using 90 degree cavosurface in addition to retention grooves. I am really starting to like using amalgam in areas such as subgingival margins where isolation is almost impossible. The results were good and the patient was very happy to have his teeth restored.

Day 13

I extracted a few teeth today. One of the patients kept talking about how he would come back to get all of his teeth extracted by me even though it was not needed. It was uncomfortable but I was quick to let him know that I was married and he apologized for talking like that. I also assisted Dr. Fleenor with a big case. His patient has hemophilia and needed to get cleared by his hematologist to get all his lower teeth extracted. The procedure also included alveoplasty and removal of bilateral mandibular tori. Dr. Fleenor did a great job providing hemostasis using gelfoam in every socket and continuous sutures in addition to collagen dental dressing on top of the ridge to assist in tissue healing.

When I was cleaning up, I think the scalpel possibly hit my finger. I didn't realize the scalpel was still on the blade holder while handing. I looked at my glove but did not see a cut. Later when I was cleaning my hands with a hand sanitizer I felt a slight burn and thought back to the scalpel and the possibility that it may have slightly nicked my hand earlier :(. There was no bleeding but I did follow the exposure control plan provided by the VA to be safe. I also completed an incident report and did baseline blood lab work. The patient is staying at the VA until Saturday so that they can be sure he does not have excessive bleeding. He was also informed of the incident and consented to the exposure protocols.

Day 12

I started the day with a large restoration on #20DO. The patient was a very sweet gentleman who needed his wife in the room with him. They told me that they were married for 67 years and had an amazing story of all the things he's been through. He was so happy with his experience and kept saying I'm so thankful to have you and we told him no we're thankful to have you and for serving our country- and he said "well that's a good point too hehe".

I delivered a set of full upper and lower dentures on the next patient and she really liked them. She said that her new teeth look just like her teeth before.

Then the patient that I performed pulpotomy on came back for the RCT. We placed rubberdam and I removed the occlusal IRM and located 3 canals. I found the ML canal to be calcified and the MB canal was curved. Dr. Snyder told me that it could be due to the incomplete instrumentation of the canals. He used RC prep as a decalcifying agent and was able to open up the calcified canal using rotary files. The patient was told that prognosis is not excellent and we just have to wait and see if it heals properly.

I also saw another patient for final impressions. I have learned to check for overextension of custom tray and learned how to take it down quickly in the lab using a rough stone wheel. Dr. Fleenor showed me a great way to see if the tray is sitting on attached tissue. He places the tray on the ridges and then takes the lower lips for example and stretches them upwards. If the tray completely dislodges, we know that the it is over extended.

Day 11- Extractions

Monday- I was told that I will be getting a lot of experience with extractions this week. It was true. I started with one extraction and then observed faculty extract all upper teeth. The patient was African American and had very dense bone. The molars had to be surgically extracted, followed by alveoplasty to get him prepared for full dentures. I also had more extractions. I learned a new technique while using the elevator and also putting my fingers around the tooth to get a feel for how much movement and bone expansion I'm creating. I also used the cowhorn that was pretty helpful for mandibular molars. Dr. Fleenor showed me how to seat the cowhorn deep in the furcation and by applying pressure to the handles of the forcep and moving it mesially and distally I can have the forceps seat all the way down in the furcation. Then buccolingual movement is used to extract the tooth.

Day 10- NCDS Annual Session at Myrtle Beach

Friday- I attended A 360◦ Slam Dunk Guide for Successful Teams by Mark Hyman, DDS, MAGD

PM: Program continues

CE Credit: 3 hours each session

ABOUT THE PROGRAM

“Change is inevitable – growth is optional.”

In this fast past, ever changing world, dental teams must commit to taking a serious look at every aspect of the practice. With a comprehensive feedback process you gain insight into your performance, which allows you to identify opportunities for growth. Learn how to diagnose, treatment plan, and deliver optimal care, whether single tooth, quadrant, or full mouth rehabilitation. Enjoy this fast paced, fun filled, dynamic seminar that will super charge your practice today!

– Understand the urgency to lead and re-align your practice today

– Rank the doctor and the team in the 35 key leadership issues for peak performing teams

Click Here for the ranking guide

– Consider key communication barriers, and how to overcome them

– Learn how to blend high tech and high touch relationship-based care

Saturday-

Saturday- Quick and Easy OSHA: Training Doesn’t Have to Hurt by Laney Kay, JD.

CE Credit: 3 hours each session

ABOUT THE PROGRAM

Let’s face it…most OSHA training courses are anything but fun. Join us for a class that will change your mind forever. Its fun, it’s fast, it’s informative, and it satisfies your annual OSHA requirements. We’ll also cover the newest infection control guidelines, new disease information, HIPAA highlights, and other relevant regulations.

The participant will be able to:

– Recognize that the dental office is government by many different government regulations.

– Understand various regulations and learn how to incorporate them painlessly into their own offices.

– Understand the importance of standard precautions and the use of PPE in the dental office.

– Recognize the importance of the CDC’s infection control guidelines and training for the dental health care worker.

– Identify strategies that can prevent occupational exposures to blood and body fluids, ALL without being put to sleep

Click here for the handout

Day 9- Pulpotomy + Restorations

I had the best day today because it was extremely busy and I learned so much! I completed 21 restored surfaces. The restorations included many buccal cervical composite and some buccal amalgam restorations (if posterior).One patient used to dip and so had a full mouth of facial caries. He told me he has quit dipping for four years now but still has to deal with the consequences. I started on #29B and moved down to 30B and 31BD. #31 caries extended distally and as I tried to excavate the caries, the pulp was exposed and it started bleeding. We placed dycal, vitrebond and restored with IRM in order to perform pulpotomy from the occlusal. I also restored #29B and 30B with amalgam. Rubber dam was placed on #31 and access was gained for pulpotomy, located 3 canals and irrigated with NaCl. Placed a cotton roll and IRM. Pt. will be coming back for RCT soon.

I also got some experience obtaining a maxillomandibular relation record with wax bite made by the lab. The patient has had a jaw surgery so his mandibular bite was to the left of the maxillary arch. It was very difficult getting the CR but it was reproducible. I took the bite registration and wax rims to the lab and communicated with them as to what we wanted. I also asked for monoplane occlusion.

My last procedure was on an older patient who was about 80 years old, had severe back problems and could not lay down all the way. He had #8 and 9 MILF composite restorations that were loose with decay. He asked to not be put back too much because he also could not breath out of his nose. It was definitely a challenge because I also could not use much water since the patient couldn't breath out of his nose. I had to stand to do the restorations but the final result was great and the patient said he can finally smile again.

It was a great day and I loved being so busy and doing different procedures.

Day 8- Extraction oops

I had more scheduled appointments today. I completed a few restorations and also an extraction of #18. There were root caries present extending all the way horizontally on the distal root. As I tried elevating I noticed that the distal root was already fractured due to caries. As I used the forceps to extract, the last bit of force was released and my forceps hit the upper teeth as I was extracting the tooth. The patient said "UHH" and I accidently said "Oops". That's something that I need to work on as sometimes it is expected. I should have warned the patient better beforehand and should have never said oops as it made it seem like something bad had happened and was not comforting to the patient. A good lesson was learned at that momement. The patient was fine and glad that his tooth was out. I showed him the extent of caries and the infection around the tooth.

Day 7- Final Impressions for Complete dentures

Today was a great day because Dr. Schmidt had scheduled several patients for me. I saw six patients and completed 13 restored surfaces. I also had a patient who presented with mesial decay on #31M but the existing amalgam was very large and the faculty showed me how to repair the mesial amalgam without taking out the existing restoration. He used a slow handpiece round bur in addition to the spoon to excavate the caries and then packed amalgam in the preparation and used a large condenser, an explorer and hollenbeck to make it flush with the margin. Then a radiograph was taken to make sure there were no overhangs, remaining caries or excess amalgam.

I also started doing removable, taking initial impressions, and practicing final impressions after observing the faculty. I learned that overextension is usually the biggest problem with dentures and before border modling I should always check the extension of custom tray to make sure it is fully seated and not over extended past the attached gingiva. Then I used compound wax to bordermold and polysulfide impression material for the final impression.

This photograph shows custom trays that have been border molded with green stick compound. The compound is softened with heat and applied to the border of the tray.

Then used Permlastic- Rubber Base, Regular Polysulfide Impression material for the final impression.

Day 6- Amalgambond Plus

I extracted two canines today #22 and 27. Learned that I should not do much buccal/lingual movements but most should be just rotation due to the conical root shape.

Also it was brought to my attention that I should not be wearing any rings during oral surgery ;)

Next, I restored tooth #4 MO.

Dr. Snyder demonstrated how to use amalgambond plus

AMALGAMBOND® Plus

Intended Use:

• Retention of direct amalgam
• Tx and prevention of sensitivity
• Capping small vital exposures

Directions:

• Prepare cavity for amalgam. Clean and lightly dry preparation
• Dispense 1 or 2 drops of DENTIN ACTIVATOR (A) into mixing well. Apply to exposed dentin for 10 seconds. Wash and dry.
• Brush a thin layer of ADHESIVE AGENT (AA) onto activated dentin surfaces. Air thin.
• Dispense 2 drops of BASE (B) and 1 drop of CATALYST (C) into a clean, dry mixing well. Mix thoroughly and brush a thin, even layer onto dentin.
• When placing amalgam, begin condensation immediately, before adhesive dries.

Day 5- Tori Removal

Remount of Full U/L Dentures

Observed complete denture delivery. Pt. returns after recent mandibular denture reline and complains of teeth not touching properly while eating. A new bite registration was taken and sent to lab for remount and re-equilibration.

The mandibular ridges were extremely flat (see top left image) and the patient had a class III skeletal jaw relationship so it was very difficult to get a reproducible bite.

Mandibular Tori Removal

A pt presented with a fractured #29 and need for a lower partial denture. Discussed mandibular tori removal at time of extraction. Patient consented to procedures.

Opened up a flap and extracted tooth #29, observed faculty remove left mandibular tori. Then, I removed right mandibular tori using a bur and lots of irrigation. The right tori was much bigger and so a conventional method was used. The tori looked somewhat similar to the following picture. Made a large mesiodistal cut going deep into the right torus- about 1-2 mm away from the apex of the tori to the point that a periosteum was used to take it off. Then used the bur again to smooth out all the areas before suturing back the flap.

Sutured bilateral tori sites with 3.0 chromic gut sutures. This was a great experience and I learned so much about flaps, tori removal and suturing techniques.

Afterwards, a dental hygienist called me for an exam.

Overall, I had a great day :)

Day 4- Sutures & FlexiOverdentures

Practiced suturing on a towel using 4-0 silk black braided suture. Learned how to do simple interrupted, cross, horizontal mattress, and continuous sutures.

Observed a wax bite rim for lower partials. Studied for Pharm section of boards part 2.

Tooth #13 root tip
Observed extraction of #13 root tip which had been infected for about 3 years. Pt. is a substance abuser of Alcohol and Cocaine and has recently been taken off of the drugs so he started feeling pain in that area. The radiograph showed periodontal radiolucency extending all the way to adjacent teeth and distoapically to the sinus. After the extraction, much cleaning up was required to get all the infection out and a small perforation was observed on the distal. Sinus perforation precautions were taken and rx antibiotics and telling pt not to blow nose.

Fate of a tooth with an Amalgam overhang = extraction
In Dr. O'Connell's words, "What not to do"

Learned about Flexi-overdentures that was done on lower dentures with canines #22 and 27- what they look like, how it clicks in and out, and how it's done using the flexi post and ball attachment. It's very important for the patient to clean their teeth extremely well to make sure they get no caries. Pt. uses prevident at least once a day. After RCT is performed, it is allowed a week to heal and the teeth are cut as close as possible to the gingiva in order to reduce torque and also to have enough space for the vertical dimension of the dentures.

Observed another partial tooth try-in and discussed tx plan designs for another partial

Fuji IX - class V restoration
Learned about restoring carious abfractions with Fuji IX, using Cavity Conditioner (polyacrylic acid) first and then applying Varnish (Fuji coat LC) to smooth out the Fuji IX. Light cure and let pt. rest for 7 minutes for the fuji Ix to cure.

Day 3- Celebrating National Hospital & Nurses Week

There was a nice lunch celebration today at the Asheville VA for the national hospital week and national nurses week.

Here are some pictures at the celebration with the beautiful staff. I have enjoyed getting to know everybody and working with them everyday.

Day 2- Observing

I observed most of the time today and studied on my free time for NBDE Part II.

Things I learned about:

Dr. Snyder had a full day of tooth try-in and delivery of partials and dentures. He uses Hydent Aerosol Denture Indicator Paste, although he also has PIP paste available. He prefers the spray because it's much easier to clean and there are no messy brushes.

He then introduced me to TAP® 3 (Thornton Adjustable Positioner)

The TAP 3 is a mandibular advancement device for the treatment of snoring and sleep apnea. It is a custom-made, two-piece appliance that snaps firmly and comfortably over the upper and lower teeth, much like a sports mouthguard or retainer. Its basic function is to hold the jaw forward so the tongue and soft tissues of the throat do not collapse into the throat causing snoring and sleep apnea. The unique design allows the patient to adjust the degree to which the lower jaw is held forward, simultaneously allowing maximum comfort and effectiveness.

Dr. Snyder told me that he used a George Gauage and the instructions can be found in the following link: TAP 3 Clinical Technique Guide

Dr. Snyder warned me that I should never make a TAP 3 for just sleep apnea but only for snoring. We are not able to diagnose and the patient has to go to their physician for the dx.

So, ask the patient if they would like something for their snoring and if they say yes, then you can Rx them a TAP 3.

After delivery of TAP 3, Dr. Snyder asked the patient to snore, and the the patient was not able to do so. Then he took the device off and told the patient to snore and the patient snored really loud. He was so happy about the device and admitted that his wife will be even happier. He also told me that he had tried the CPAP already and hated it.

Finally, Dr. Snyder emphasized the need for a Bite Tab . All patients using mandibular advancement orthotics for the management of sleep disordered breathing will feel temporary changes to their bite each morning. The bite tab was then created for the patient so that he can recover his bite.

RCT #20 - Using EndoSequence Endodontic System by Brasseler

I was so excited to observe Dr. Snyder perform a root canal on through PFM #20. He used two different burs, one to get through the porcelain and another to get through the metal for the access. He then put on a rubber dam and told me that it helps him with the orientation if he doesn't have the rubber dam on for the access. He then used SS files to get working length and from there used rotary files by Brasseler. The nice thing about the rotary files system is that if the file is getting close to bind, it will beep and rotate in the opposite direction. He then used taper-matching paper points and gutta percha to obturate. It took only 20 minutes for the whole procedure and the patient found it completely stress-free. The access was then filled with composite and the patient was told that prognosis for premolars is fair-good and the procedure went well so we just have to wait and see how the tissues repond and heal.

Day 1- First Rotation in Asheville VA

Asheville VA Medical Center is very beautiful, clean and new. I was so impressed as I walked in the VA today.

I was introduced to Dr. Snyder as my preceptor for the week since Dr. Fleenor is off for his Birthday.

Wendy, Dr. Schmidt's secretary, took care of all the administrative stuff such as finger printing to get my ID and receiving 6 sets of new scrubs with my name on it :).

I'm official now and can see patients.

First day was definitely a good day.

I'm going to blog about everything that I learn everyday.

The first patient had severe renal disease- so the first question Dr. Snyder asked me was- what do we need to watch out for? The answer was how much medication we give him and more importantly the anesthetic.

I observed Dr. Snyder lay a flap and perform a surgical extraction.

I was then on my own to see another patient and extract tooth #16. This patient presented with facial swelling on the left side of his face. This tooth was a little difficult to extract as the PDL was almost non-existent. I learned that non-opposing teeth with no occlusal trauma start to lose their PDL as it's not used for proprioception. After the extraction, Dr. Snyder prescribed antibiotics because the infection was diffused and not localized.

Next patient was a very nice man who had to have four teeth extracted before having radiation therapy for cancer. Although he was not in any pain, the important thing was to get rid of all infections and extract questionable teeth. The extractions were pretty simple as the teeth were also periodontally involved. The patient did really well and was very appreciative.

My next two cases were interesting as Dr. Snyder had me go back and forth between operatories to anesthetize each patient and then perform extractions. One of these patients needed tooth #31 extracted and he explained to me that he has taken out all of his upper front teeth himself but just couldn't get far enough to take this one out. He presented with He was a big guy who liked to talk a lot and he told me all about his previous girlfriends, etc. Finally I was able to get started but it was extremely difficult to get him numb because of the presence of inflammation creating a lower pH (more acidic environment). The non-ionized (base) form of local anesthetic is capable of diffusing across nerve membranes and blocking sodium channels. A decrease in pH shifts equilibrium towards the ionized form, delaying onset of action.

Finally when I extracted #31, the patient was so relieved and confessed to me that he initially thought that I wouldn't be able to extract his tooth. But he thanked me and said he was glad it was out.

Overall, I had a great day today and learned so much. Dr. Snyder quizzed me along the way and that helped me learn more.