I had no idea just how busy I would be once I started working in the Midwestern University Dental Clinic. My partner, Nozar, likes to keep our schedule loaded, which is a good thing. We rarely have cancellations, and when we do, we still have plenty of things to keep us busy.
Right now, a typical day for us is four patients. That isn’t a lot for a private dental practice, but for a student clinic it is. And this is just one month into my first clinical year. Nozar was seeing six or more patients at the end of last year with his previous partner.
A week alone
Fourth year students go on several rotations that last anywhere from one to two weeks. Nozar had a one week rotation in our pediatric clinic, which meant I was left to my own devices.
Despite flying solo, we still kept my schedule pretty heavy. I was seeing between three and four patients every day on my own. We avoided scheduling procedures that I absolutely needed a more experienced partner for.
What I did
Below is a list of the stuff I did on my first solo week.
- Class II & IV preps + composite restorations
- Periodic Oral Evaluations (POE)
- Comprehensive oral exam
- SRPs and prophys
- Panoramic x-rays
- Flexible-base partial denture
Everything is easier with a partner, but learning to work alone is important. There is no better way to master Axium (our EMR system) than to actually use it. No one can really teach you how to use it, and you won’t learn by watching your partner use it either.
Comprehensive exams are hard to do by yourself. A comprehensive exam consists of the following:
- FMX – Full-mouth x-ray series of 18 x-rays with completed radiographic findings
- Perio probing with all depth measurements, bleeding on probing, and plaque accumulation documented in Axium
- DMFT (Decayed, Missing, or Filled Teeth) – A complete clinical assessment of every tooth in the patient’s mouth
- Full medical health history, dental history, and all medications
- Intraoral and extraoral exam
- Consent forms
- Extraoral photographs
- Upper and lower impressions to be used for fabrication of stone model casts
We usually book comprehensive exams for three hours. I was able to finish all but the impressions and photos on one of my comp exam patients by the end. With practice, you just get faster and more efficient.
Periodic Oral Evaluations
Every clinical suite at Midwestern has its own hygienist. After every hygiene appointment, a dental student is required to do a POE exam on the patient. This can introduce additional stress when you are already running on a tight schedule, just like a real dental practice!
A basic POE at Midwestern consists of the following:
- Radiographic evaluation of new x-rays
- Evaluation of the hygienist’s perio charting
- Extraoral and intraoral exam
- Updating medical history and medications
- Clinical evaluation of the patient’s teeth and documentation of changes
SRP and prophy
I had a few SRP (scaling and root planing) patients on my schedule, meaning I had to do anesthesia without the reassurance of my partner. On one patient, I did an IA, MSA, and PSA, all on the right side, with local infiltration on teeth that had especially deep pockets.
Nothing builds your confidence faster than accomplishing something by yourself. After doing a bunch of injections alone, I became much more comfortable with local anesthesia. That’s not to say that I am cavalier about them, but I don’t need Nozar to hold my hand during injections anymore.
We occasionally get patients with third molars, or microstomia, or interesting anatomy / pathology just beyond what we can see with an FMX. In those cases, we take a panoramic x-ray.
I have now identified suspected carotid artery plaques in three patients. The remarkable thing is, I’ve only taken five panoramic x-rays. All three patients were on statins, and one patient had particularly large radiopacities where the carotids run. Unfortunately, I learned during the course of her comprehensive exam that she had already suffered from a stroke and had a brain aneurysm among other major health problems. Because she was an ASA 3 patient, we had to dismiss her from the clinic (we only treat ASA 1 and 2).
We have the benefit of working with dental radiologists for every CBCT and panoramic x-ray we take here at Midwestern. I have learned a lot about x-ray interpretation, especially the anatomy outside the mouth.
I did a class II and class IV composite on the same patient. She had a large MOD on #18 and a fractured #8 that needed to be repaired.
Composites in the clinic are so much funner to work with than they were in the simulation clinic. First of all, the composites match actual teeth. Second, we have a broad array of composites to choose from, and they aren’t all expired!
For the MOD on #18, I prepped the way we learned during our 2nd year, and then spent my time placing and contouring the composite. Dentists generally fall into one of two camps: carvers, and sculptors.
When it comes to wax, I am a carver. I add bulk material, and then carve it down to the proper shape. Composite on the other hand, I mold to match the surrounding tooth structure.
My personal philosophy on sculpting composite comes from the fact that I can match the soft composite to the hard tooth structure easily to create primary and secondary anatomy. When I cure the composite, the only reason I need to use a bur is for flash and small adjustments to the occlusion.
For #8, I matched the enamel shade to the patient’s enamel and then went one shade darker for the dentin shade. In the end, the translucency was indistinguishable and the colors were a near perfect match. The patient was extremely happy, and that makes me happy.
I had my first partial denture case during my solo week. My patient is in her late 80s, and she still has most of her teeth. It is amazing to see edentulous 30-year-olds in the same clinic that we see elderly patients with all or nearly all of their teeth.
My patient wanted us to give her a “fake tooth” to replace the one we had extracted before. In consideration of her budget, we opted for a flexible base partial denture. The esthetic outcome was great, but you’ll have to take my word for it as I only took pictures of it in the model.
I spent a lot of time planning the partial denture on the model, and then on the diagram I sent to the lab. The only way to be absolutely sure they’ll get it right at the lab is to give them more information than they need.
When the partial came back, it fit perfectly. Although she said it felt weird to have something in her mouth like that, she couldn’t believe how well it fit. We didn’t have to make any adjustments!
Three weeks with Nozar
The rest of my month was spent with my partner, Nozar. We did so many things I struggle to remember them all. Below is a list of what I can recall:
- CBCT and implant planning in Anatomage
- Guided Bone Regeneration (GBR)
- Multiple root tip extractions from an emergency patient with a space infection
- Third molar extractions on a 60-year-old patient
- Implant uncovering on a complete arch
- Crown lengthening
- Root canals on #19 and #29
- An apicoectomy on #12
- Multiple Zirconia crowns
- My first same-day e.max crown
- Denture relines
- Class Vs and IIIs
- A few extractions and restorations I’ve since forgotten
- Lots of the same stuff I talked about during my solo week (comp exams, POEs, FMX, panos, etc.)
The days in clinic are long, and we end up doing a lot of stuff. Although I think that’s most of what we did, I’m probably missing a few things here and there.
A typical day in the Midwestern Dental Clinic
- Arrive by 7:45am
- Setup for first case
- Huddle at 8:00am
- See first patient at 8:30am
- Lunch at 12:00pm
- First afternoon patient at 1:00pm
- Finish by 4:30pm
- Notes and cleanup
- Leave by 5:00pm or 5:30pm
The time we spend on the clinic floor tends to be rather intense. Because Nozar and I overlap patients and split up a lot, we are always busy. We also have a shortlist of patients to call in case a patient cancels at the last minute.
I leave the clinic every day feeling tired but fulfilled. This is by far the most rewarding experience so far in my dental journey.
Every journey is unique
I have learned that our experience in the clinic is largely determined by us and our partner. Nozar is really interested in implants, which is why he placed over 20 of them before starting his 4th year. We currently have over 25 implants scheduled over then next year.
You will probably have to make some sacrifices if you want to chase the thing that interests you. Neither Nozar nor I are particularly interested in orthodontics. We have chosen not to be involved with ortho cases any more than we have to be.
I really want to get experience with molar endo. Unfortunately, implants have meant that many patients choose to forego root canals. Nozar and I have been fortunate though because we recently picked up several patients in need of more than 15 root canals between the three of them!
Some students spend more time on their notes, others less. There are those students who want to understand the billing and how it works, and there are those who couldn’t care less. I am trying my best to understand everything, and that has meant skipping lunch every day, and spending a lot of time after the clinic reading about medications, billing codes, and perfecting my notation style.
Stepping outside of my comfort zone
I have learned so much more than I thought possible in just over one month. Who knows how much more I can learn over the next two years in the clinic!
One of our graduating fourth year students last year told us that the clinic is the place where we should step outside our comfort zone. Those of us who go straight into a job or ownership after school won’t have the luxury of faculty to fall back on.
I have tried to follow his advice and push myself every chance I get in the clinic. Not comfortable doing a root canal on #19 because you’re afraid of missing a canal? Do it now, while the endodontist can tell you what you did wrong and what you missed.
Our clinic is affords us the opportunity to work side-by-side with specialists in every dental specialty. I have done a root canal with an endodontist, and I have done surgery with our oral surgeons. When crown lengthening, we work closely with one of our periodontists. How much they let you do depends on how competent and confident you are.
This year promises to be full of growth and opportunity. I will be flying to Tonga for a mission trip in November, and then flying to Columbia for an implants course in May. If ever I felt encumbered by my 2nd year, I feel a huge weight has been lifted and I’m free to soar with the safety net of specialists and faculty afforded us in the clinic.