My first week in the dental clinic was full of firsts. My first crown prep and temporary, my first extraction and bone graft, my first SRP, and my first bridge removal. To be sure, I only assisted on some of the procedures. But my partner Nozar has thrown me in the deep end, and it’s sink or swim!
On Tuesday I assisted Nozar with a bridge removal. Being that this was my first week in the clinic, we are still getting a feel for how we will work together. Nozar made it pretty clear that he wants us both to work very quickly and efficiently this year.
Most student pairs see one or two patients in the morning, and one or two more in the afternoon. Our plan is to see many more patients than that. On my very first Friday, we split off and treated four patients between the two of us.
My First Crown
On Tuesday, I prepped a crown inside a patient’s mouth for the very first time. Although things went well enough, I was very slow, and I struggled to finish my temporary crown on time. We use a different technique in the clinic than I learned in the simulation clinic for temporary crowns, and Tuesday turned out to be an unexpected learning experience.
Our suite has 14 operatories and 28 students. We all share three faculty members. On Tuesday however, one of our faculty was out sick. On top of that, my patient was 20 minutes late. By the time I was ready to cut my very first crown prep, I was already starting almost 40 minutes behind due to a long line for a start check (permission to start the procedure).
This ain’t plastic anymore
When I started prepping tooth #5 for a crown, I was surprised at how much slower it is to cut natural teeth than plastic. I had prepped a few natural teeth in the simulation clinic, but they were all dry and old.
Of course, no one wants to hurt their patient by nicking gingiva, or damaging neighboring teeth, so I was already taking things slowly.
What once took me 10-15 minutes to do in the simulation clinic, now took me nearly 45 minutes in the dental clinic. I was pretty disheartened afterward when a faculty member told me that my margins were way too narrow.
This ain’t the simulation clinic either
After explaining to him that we had learned to cut a 0.5 mm axial margin for zirconia preps, he told me that there was no reason that it shouldn’t be at least 1 mm, despite what we learned during our first two years.
The reasons he listed are as follows:
- It doesn’t hurt the tooth, even if you do remove more natural tooth structure.
- It’s better for the prep, even though zirconia is strong stuff.
- Larger margins are much easier for labs to reproduce.
Every doctor has their own ideas about prep dimensions, and I must abide by the standards of my faculty graders. It is interesting that there can be such a difference of opinion from one side of the street (pre-clinical) to the other (clinical). At least I know better what will be expected of me next time.
My first bridge
Bridges are hard to come by at our school. These days, everyone wants implants, so bridges are increasingly uncommon. My first bridge removal was also Nozar’s first. The removal itself wasn’t difficult. Cutting through PFM is pretty easy compared to some other materials.
The bigger struggle for Nozar and I was trying to get the temporary to seat correctly. Occlusion can be tricky, especially when it’s your first time. We had some help from faculty who showed us a few clinical pearls.
One trick we learned was to put the articulation paper on the opposite side of the arch to see if the patient can bite down on it and hold it in place. If the paper slides out easily, then you know the other side is too high.
I also learned not to apply cement on the occlusal portion of the intaglio surface. Only cement the axial walls I was told, because anything on the occlusal will just make seating more difficult.
Nozar taught me to relieve the intaglio surface slightly with a bur. In the simulation clinic, we learned never to put a bur inside the intaglio surface. We did learn however that the temporary material we use (Integra) has a tendency to shrink. Because of this property, it’s a good idea to open the intaglio surface up slightly with a few judicious strokes of the bur.
Eventually, we managed to seat the temporary bridge properly. Our patient came back for a separate appointment on Friday and told us that there was a sharp spot on the bridge temp that was bothering him.
When patients are numb, they can’t feel things that might be a problematic later on. It’s not uncommon for patients to come back a day or two later with minor complaints about discomfort. Ideally, dentists strive to have as few of these problems as possible because it is inconvenient for patients and it affects a dentist’s bottom line.
My first extraction, bone graft, and pedicle flap
The video featured on this article is an example of the oral surgery case we had on Wednesday. At first, I assisted Nozar with the extraction of tooth #12. Our initial plan was to place a same-day loaded implant. Although that was our goal, we knew that it was unlikely.
After the tooth was extracted, it became clear that our patient had almost no attached gingiva on the buccal side of the tooth root. Although we initially worried when looking at the CBCT image that her buccal plate may have been too thin, the biggest problem in the end was her lack of attached gingiva.
Surgery to the rescue
The oral surgeon took over, and decided to perform a pedicle tunnel connective tissue graft on the patient. As simply as I can explain it, he cut into her hard pallet behind teeth #11, #12, and #13, all the way down to the bone.
He then flapped the connective tissue from underneath the attached gingiva and ran it through a tunnel he made at the #12 site. After packing bone graft material where the implant had been, the surgeon then covered it up with the pedicle graft.
I asked the surgeon why he had performed a pedicle graft instead of a free graft. He explained that he needed soft tissue to cover the bone graft. However, free grafts are avascular and rely on underlying periosteum and bone for their blood supply.
Bone grafts are avascular, and covering them with soft tissue is not an option. A pedicle graft is vascular, and can therefore be used to cover avascular bone graft material.
A surgical procedure like this is usually done in the oral surgery suite. This was the first time it had been done in one of the clinical suites and I was lucky enough to be a part of it!
My first SRP
On Friday I performed my first SRP treatment. My patient had deep pockets on tooth #19, and smaller pockets on tooth #30. Before completing the SRPs though, I gave her a thorough prophy (teeth cleaning).
She was a smoker, so I tried to remove as much staining as I could with my ultrasonic scaler and tooth polishing. After the prophy was complete, I performed my second ever inferior alveolar block for SRP on tooth #19.
While I waited for the patient to get numb, I applied topical to tooth #30. Unfortunately, topical wasn’t enough, and she yelled out in pain as I started the SRP. Nozar and I decided to give give her local anesthesia instead and this allowed me to finish the procedure.
I then performed SRP on #19 and watched as the tip of my ultrasonic disappeared deep into her pockets. I was able to move the scaler all the way through the furcation on her molar from both the buccal and lingual sides of her tooth.
Exhausting but so worth it
I was thoroughly exhausted every day this week. The stress and adrenaline of treating live human patients feels like running a marathon. My days started at 7:45 am in the clinic and ended after 5:00 pm every day. But I went home every day feeling completely satisfied with my decision to become a dentist.
By the time I got home, I collapsed on the couch. With a baby on the way in three months, I really hope that the exhaustion of working in the clinic will die down by then!
Next week I will perform my first endo on a live patient. I have to study our endo protocol this weekend and make sure I memorize all of the steps from start to finish. My clinical coordinator likes to test our commitment and ability. You get one chance to show him you know what you’re doing. I plan not to let him down!