On my previous clinical rotation I shadowed a third year student and helped him with a large amalgam removal and buildup. Then I watched him scale excess cement from multiple crowns on another patient.
Today I walked in to the clinic early for my second clinical rotation. One student asked if I would like to watch he and his partner perform four extractions in about an hour. Then, another student asked if I would like to assist him because his partner was out sick.
My first third molar extraction
The third year student, whom I’ll call Tim, had a third molar extraction scheduled. I am very interested in oral surgery so I thought this would be a good opportunity to get my feet wet. Our patient was an older man with a lot of good stories to tell. I asked him questions and kept him talking while Tim prepped for the extraction.
Unlike much of my class, I was never a dental assistant or hygienist. I have no idea if I am using the suction right or not, but I figure that the main goal is to keep the field clear so Tim can see what he’s doing.
We did the extraction standing, this afforded us the most mobility and also allowed Tim more leverage for the extraction I assumed. He showed me the radiographs of our patient’s tooth and pointed out a pocket of infection surrounding the root.
Tim shows me the ropes
“The root looks pretty gnarly but straight, so I am hoping for a relatively easy extraction with this patient.”
Tim opened the oral surgery cassette and then proceeded to cut the patient’s Periodontal Ligament (PDL) surrounding the tooth.
“You want to start with the PDL and then we will sort of work the tooth free from the socket.”
I did my best to keep the field clear of blood without getting in Tim’s way.
“Next we loosen up the tooth by rocking it back and forth. I give it some love with a gentle figure 8 motion and that really breaks up the interradicular fibers. A lot of people hate doing extractions back here in the mouth because they want to see everything they are doing. You just have to get comfortable with working in places you can’t see when you do 3rd molar extractions.”
The tooth came free just as easily as Tim had hoped it would.
“See that root? Exactly what I expected!”
The root had been decimated by the chronic infection that our patient had been suffering from. Our patient was unaware that a chronic infection could decalcify bone so drastically.
“Could an infection eventually go systemic and kill you?” the patient asked.
“It’s certainly possible, and it does happen, but it’s pretty rare” Tim replied.
Trying to be a good assistant
Our next order of business was to remove the granulation tissue that had formed inside the infected pocket. At this point, my job as assistant became much more important.
“I need you to suction that little bit of granulation tissue there, you see it?”
A clump of flesh slid into the open socket where Tim was pointing. Using the surgical suction I chased after the infected flesh and heard it block the opening. I pulled the suction back out of the socket and saw the ball of granulomatous tissue stuck to the end of the suction.
Tim cut off the granuloma as I proceeded to suction more of them from the periphery of the socket.
“The goal is to make the floor of the socket glassy smooth,” Tim explained.
Five minutes later and we were packing the patient up with gauze and getting him ready to go home.
Tim got to work charting the procedure and setting up a followup appointment. He told me that learning the clinical software was probably the worst part about working in the clinic. The software is cumbersome and has a steep learning curve, but it does the job I guess.
Our patient was happy with how easy the extraction had been.
“I should have had that tooth out years ago!”
CAD/CAM is complicated
We escorted him out of the clinic and then brought another patient back. Tim and his partner had placed six crowns on her the day before and she had tooth pain when she bit down. She was back for her followup visit and Tim was planning to fix her occlusion slightly.
“Our CAD/CAM software is kind of sketch sometimes, so you have to over bulk some areas or else the safety catches and it will just leave a bubble in your crown.”
So Tim removed the bulky area of the crown and also scaled off some excess cement around the gum line. The whole process took no more than about twenty minutes and then we moved on to our last patient of the day.
She was a middle-aged woman who had been a dental assistant for twenty years. I felt even more nervous now knowing that she could see right through my facade!
Smoothing the margins
Tim placed an onlay yesterday and we were going to make some adjustments.
“I always leave some bulk on the margins or else they get damaged before placement.”
Tim showed me what he meant with the mirror and then got to work blending the margins with our patient’s natural tooth. Twenty minutes later we checked our patient’s bite. She said that there was something sharp poking against her gum. Tim looked hard but couldn’t see what she was complaining about on any of the margins. A little while later, we squirted some water for a better view and out popped a piece of cement.
“There’s the problem!” Tim said, holding the tiny shard of cement up so the patient could see it.
We finished up with the patient and walked her out. Tim thanked me for helping him out with his patients today. The bad thing about rotating on Fridays is that people leave early for the weekend. The clinic is open until 5:00, but here it was 4:00 and only one patient remained in the suite.
I learned a lot today about using CAD/CAM technology, placing onlays, and doing 3rd molar extractions. Getting to assist for both of my clinical rotations is pretty rad too. I know that I still have one year of pre-clinic after this, but I am really looking forward to getting into the clinic.