Today I observed the pedodontist treating a female child. The child came in for her first dental visit. The doctor gave her a child prophy and fluoride foam treatment. Before having the patient come into the operatory, I observed the doctor turn off the lights and turn on the disco lights and presented the child with a princess wand. Then, she sat on the princess chair! He gave her a handheld mirror; so that she could see everything he was doing which actually was the key in allowing the patient to cooperate. The pedodontist practiced the “tell, show, and do” technique which worked amazingly for the child. The child has a thumb sucking habit, so her upper incisors were proclined and her lower incisors were retroclined. I realized that after the treatment, the dentist explained to the mother about her thumb sucking habits privately. I noticed that with every instrument, he explained and showed the child how to use it before it was placed in the mouth. I realized that being a pediatric dentist takes a lot of patience and you have to be animated to have the child cooperate. I learned that children need to be given choices, like which prophy paste or fluoride flavor they want to use, in order to get them to cooperate. After the child prophy and fluoride therapy was done, she was given a bag full of gifts for being such a nice patient. She was thrilled and took a picture with Dr. Payne, the puppet. 

G.Y., New York University College of Dentistry, Observation 3

Female patient presented to the dental office for #14 crown cementation. I learned that the crown that was fabricated from the lab was a butt margin porcelain crown which meant that the margins were covered in porcelain so that the metal didn’t show on the buccal or the lingual margins of the crown. Also, the crown had a kaitlyn loop on it with a dental floss attached to it so that it’s easier to handle/remove the crown when modifications are needed. I learned how to remove the temp crown with a crown removal forcep without placing so much force. In addition, once the temp crown was removed, the temp cement was removed from the tooth and the permanent crown was tried in with a piece of articulating paper on the sides to check for interproximal contact on both mesial and distal sides. A slight adjustment was made interproximally and then a bitewing x-ray was taken to check for the marginal fit. After the x-ray was analyzed and confirmed to be adequate, the kaitlyn loop was removed with a bur. I learned that if you put Vaseline on the interproximal surfaces of the crown especially on the middle and occlusal third, then it will be easier to remove the excess cement around the embrasure of the crown. The assistant mixed the cement mixture and I observed the cementation of the #14 crown. The excess cement was removed with floss and the patient was biting on the cotton rod for 12 minutes for the cement to set. After that, an extra-oral picture was taken to show the patient how it looks in her mouth.

G.Y., New York University College of Dentistry, Observation 2

Today I observed a cementation of a gold post and core of tooth #7, a shoulder preparation, fabrication of a temporary pre-fabricated crown, final impression technique of the prepped tooth, and then observed the temporary cementation of the #7 pre-fab crown.  

Patient presented with a past root canal treatment done on #7, but had recently fallen, hitting her front teeth, especially # 7 and #8.  She was seen by an Oral Surgeon to make sure that there was no bone or facial fracture and was given a splint to keep her anterior teeth intact. 

I learned that there are different treatment options for this patient.  She could have extracted #7 and placed an implant, or extracted #7 and make a 3 unit bridge from #6 to #8, or do ortho to recline #7 and then prep it to make a PFM crown or an all ceramic crown.  Since the patient fell and could have fractured her root or crown of #7, ortho tx to move tooth would cause more fractures, so the prognosis would be poor; therefore, ortho treatment before crown prep would not be a treatment option.  

The observation first began by opening up the access of #7 by removing the temp filling with a bur. Then the gold post and core of #7 was inserted. The post was refined with a bur, then it was checked with occlude spray to observe for pressure/tight areas. Once the post and core fit adequately, then it was permanently cemented which took 12 minutes to cement.  Then a shoulder prep was done with a bur, made the margins clear and checked to see if the prep was tapered and not labially reduced, in another words made the prep slightly more lingual on the facial side.  Then I observed the selection process of a pre-fab #7 crown.  Once the pre-fab crown was chosen, the margins were reduced to make it fit the prepped tooth.  A mixture of monomer and acrylic was made and poured into the pre-fab crown, and then the crown was placed into the prepared tooth to get the internal fit of the pre-fab crown.  Then, the excess was removed around the margins.   

After that, I observed the final impression of #7 prepped tooth.   Since the patient has existing porcelain veneers on her anterior teeth, it’s a good technique to put Vaseline on the veneers and to block out the embrasures with wax, so that when the impression is taken and then removed, there is no chance of her other porcelain veneers coming out.  I learned how to analyze an impression to see if the margins came out or not.  I observed the selection of the final shade of the porcelain crown which was B1. A Polaroid film was taken, so that the lab could match the correct shade. Then, the pre-fab temp crown was refined with a mixture of monomer and acrylic and the excess was removed with a bur.  Finally, once the fit was adequate, then the pre-fab temp crown was cemented with temporary cement.  I also observed the bite registration technique; the registration of the anterior incisors where taken so that the lab has the patient’s occlusion which helps with the fabrication of the porcelain crown.  Then the lower anterior incisal impression was taken with alginate, so that the lab could pour up a lower anterior cast as a guide to make the porcelain crown and check the occlusion. 

In conclusion, today’s observation was a great learning experience.  I learned that we should never put Vaseline on the prepped tooth to get the internal fit of the pre-fab crown because it could contaminate the cements.  Also, I learned that it’s more efficient to fabricate the temp crown before taking the final impression of the prepped tooth. 

G.Y., New York University College of Dentistry, Observation 1

Last Monday was a very educational and rewarding experience. I observed many procedures done by different specialists.

The first one that I participated in was Phase I Therapy of single implant placement on a middle-aged male patient. The surgery was done by an oral surgeon. He used an approach of first creating a flap to help visualize the path of implant insertion. I asked him afterwards whether there was a specific reason that he created a flap first instead of directly “drilling into bone”, and he said there wasn’t, except for the fact as I mentioned to enhance visibility (good reason for me if it means implant will be placed correctly). I was able to see on the x-ray the alignment of the placed implant, and according to my still limited knowledge, it was excellently positioned.

The treatment of the same patient was continued by the general dentist who cemented a temporary bridge in area where implant was placed.

In another treatment, the endodontist performed a root canal therapy on the mandibular molar of another patient. She demonstrated the lateral condensation technique when obturating all 3 canals. This time I saw her using an apex locator, a great device which as she explained showed her the apex both radiographically and clinically. She told me that it is the best to stay within 0.5 mm around the apex when placing master cone with the cement, because that will prevent excessive widening of the apex and perforation of the canal. Upon completion of the RCT I saw the final radiograph, which again showed a very successful end result.

After RCT, the patient was transferred to a different room, where the treatment continued with the core buildup and crown prep done by the general dentist. The patient did not need post and core placements because there was enough tooth structure to ensure longevity of the fixed restoration with the composite core. The finish line of the crown prep was a combination of shoulder with bevel and chamfer, done as such to avoid unnecessary compromise of the tooth structure. After the final impression and shade selection, a temporary crown (constructed at the chair-side via “block technique”) was cemented and patient was dismissed.

Throughout the entire time, what was most apparent in the office was the nature of the comprehensive and personalized treatment, excellent pain control and sensitivity to patient’s comfort. Interaction between Doctor and Patient was constant and conducted in comfortable yet respectful manner. The pain control was done not only during the procedure but also after the visit; because at the end of the treatment Dr Dorfman made sure the patient received post-op instructions and pain medication.

E.T., New York University College of Dentistry, Observation

Today I saw a couple of orthodontics cases and practiced taking photos with the digital dental camera. I have wanted to learn how to take pictures for a long time, so I am glad that I finally got the chance to do it. I like that our technology is becoming more and more digital, it helps the patient and the dentist communicate better as well as making things easier to keep track of. Both orthodontic cases that I saw today involved bracket placement. The first patient was receiving orthodontic treatment in part to correct her TMJ pain. I learned about how to place the brackets, what the correct angulations may be, and that it’s a very precise slow process.

A.L., New York University College of Dentistry, Observation 2

Today I learned that dental practice management can be rather difficult. At the office, a crown that came from lab was fitting poorly at the margins, the occlusion was high, and internal fit was not proper. Dr. Dorfman taught us that it is unacceptable to give the patient such work. In fact, he took two more tooth impressions and sent one to the original lab and one to a new lab. This way, he would be able to see which lab did a better job with the crown and would create more of an incentive for the original lab to improve. I learned that it is important to stay on top of the lab that you work with and to create high standards of care, especially since the lab receives a large amount of money for the top notch work that they are supposed to do. The patient was not entirely happy that he did not receive his crown, but also appreciated that the dentist was honest and looked out for the quality more than the time it takes to finish the work.

A.L., New York University College of Dentistry, Observation 1

This Wednesday was a great learning experience for me.  I had the opportunity to watch the Doctor perform a DO dental caries excavation on tooth #20; however, the caries was very extensive, and there was a pulp/nerve exposure. He then performed a direct pulp cap and bonded over it with composite to complete the restoration, and informed the patient of the possibility of future root canal therapy on that tooth. So I will never forget what a direct, or indirect, pulp capping procedure entails, I did some research on the topic:

Vital pulp capping is a controversial procedure as many clinicians are uncertain of the long-term success when compared to the proven long-term success of root canal therapy.  Vital pulp capping basically entails dressing exposed pulp to maintain vitality.

For success, the tooth should be asymptomatic and have bleeding controlled. 

There are basically two techniques.  First the area is disinfected and then calcium hydroxide placed directly on the pulp.  Then the calcium hydroxide should be covered with RMGI or zinc oxide eugenol then dentin bonding agent and permanent restoration placed.  The second technique involves total acid etching the cavity preparation created with 32% phosphoric acid then dentin bonding agent and a few layers of primer followed by RMGI and a permanent restoration. 

M.C., New York University College of Dentistry, Observation

The result of the direct pulp cap mostly depends on ability of dentist and capping material to prevent microbial leakage. 

Indirect pulp capping is a procedure performed when a dentist comes close to the nerve/pulp when excavating caries, but there is no penetration or exposure.  This is done to stimulate reparative dentin formation and prevent the need for root canal therapy

After the completion of re-treatment of root canal therayp (RCT) on #22, a patient presented to the appointment with the tooth being prepared for the post placement.

Before starting the procedure, I took a maxillary quadrant alginate impression of the patient’s mouth. In the maxilla one of the fillings had an overhang so we blocked out the undercut with blue wax placed in the interproximal space from both the buccal and the lingual. Also, we placed some Vaseline on the buccal and the lingual surfaces of that same tooth in order to avoid problem during ejection of the set alginate impression from the mouth.

After the alginate impression, we went ahead and took off the temporary bridge. I cleaned the remnant temp-bond from the teeth and dried them up, after which I took a bite registration by putting some JetBite polyvinylsiloxane material on a triple tray. I asked the patient to bite down gently on the tray and after waiting for 3 minutes I received my bite registration.

Afterward, we went ahead and took out the cavit G and a cotton roll from tooth #22 which will receive a post. I then took a yellow post system and tried it in the canal. I adjusted the yellow post system to the estimated height of the future permanent post and I placed some notches on it for retention during impression taking. Then we prepared a quadrant tray, and put some adhesive on it. I dried up the quadrant, put the yellow post system inside the canal of #22 trying to keep the post system parallel to the long axis of the tooth. Then I took some light body and syringed it around the yellow post system inside the canal of the tooth. As I was putting the light body around the post system, my assistant started putting Improgum on the quadrant tray, after which I took the tray with the Improgum and gently sat it in the patient’s mouth. The post system in the impression turned out to be parallel to the long axis of the tooth which enhanced the quality of our impression. The light body (in blue) covered the whole margin of the tooth and its close surrounding tissue.

After we were done with the impression, we irrigated the canal space of #22 with some saline, we put a cotton pellet inside the canal and covered it with Cavit G – this kept our root canal isolated from the oral environment. Then we took our temporary bridge and sat it back into the patient’s mouth. After making sure that the patient was comfortable with the temporary bridge, we dismissed the patient. 

R.F., New York University College of Dentistry, Patient 3

Today I learned how to make a cast post via the indirect technique (done extraorally) vs. via the direct technique (done intraorally) as it is done at the college.

Everything starts similarly in both scenarios: We use the Peeso reemers to open up the canal to make sure the walls are parallel or divergent occlusally without any undercuts. This design ensures that when taking an impression, the impression material does not get stuck in the canal. We leave about 7-8mm of gutta percha at the apex and rinse with sodium hypochlorite. Afterwards, we take a post system and try to fit the plastic post cones into the canal, making sure that the tip of the post system is in contact with the coronal part of the gutta percha. After this is achieved, we take an impression tray and  put some Impregum into it and at the same time we load the light body material into the canal of the tooth where the post system is. We leave it like this for 6 minutes and then we take it out and get our final result fast and efficiently.

I prefer to use the indirect method for making cast post over the direct method used at the college for several reasons: Reason number one is that the abovementioned method saves a lot of time if doing one post and especially if doing a few posts. The method that we use at the college to build up the plastic cast post cone with duralay is also reliable but it is very time consuming and it requires much more time when doing several teeth simultaneously. The second reason why I like this method is because it is easier to do than at the college if it is done properly. It is certainly easier to take one good impression with 6 different posts as shown below instead of building up all 6 plastic post cones with duralay.

However, there are a few things that need to be kept in mind when doing the indirect technique cast post method: First of all, when doing an impression of multiple posts one must make sure that the canals are prepared in such a way so that when taking the impression they all have a similar line of draw, that is they must be more or less parallel to one another. Second of all, one must make sure that all post cones have been inserted all the way down to the gutta percha before taking the impression in order not to have a gap that could potentially fill up with bacteria. Third of all, it is very important to know how to handle the impression material, when to bleed it, and the proper techniques for seating it and taking it off.

R.F., New York University College of Dentistry

Patient presented for the placement of implants with the oral surgeon. Patient had a 3-unit bridge teeth #3-5, with a mesial bony defect on #5. After the bridge came off, area #4 and 5 was left edentulous and needed to be restored. The patient preferred implants for the area #4, 5 and 8.

The oral surgeon started the procedure by allocating where to place the implants. Then he took a #15 blade and created a flap through the crest of the alveolar ridge. Suctioning and irrigation were done during the whole implant placement procedure. The General Dentist who was going to restore the implants was assisting the Oral Surgeon which made the procedure even more efficient because the two specialists were able to coordinate the optimal placement of implants for the benefit of the patient. The implants were placed perpendicular to the occlusal plane. However, the anterior implant was placed more subgingival than the posterior implants, for esthetic reasons. The whole procedure was done under local anesthesia and nitrous oxide.

Although the patient was really anxious before the procedure, the good social and professional techniques of the oral surgeon made the procedure as smooth as placing a sealant on a tooth. After the placement of the implants was completed, the oral surgeon sutured the flap sites and achieved hemostasis. During this time the general dentist relined the patient’s existing flipper in order for it to fit the mouth well after implant placement. We took a PAN of the patient right after this procedure was completed.

Both the oral surgeon and the general dentist were satisfied with the way these implants looked on the PAN. The implants had nice angulations and stayed away from adjacent teeth and their roots. The oral surgeon commented that he used the indirect sinus lift technique when placing these implants by lightly hammering the #4 and 5 implants into the sinus in order to push some bone out because the surgeon knew from the previous PAN that we needed 2-3 mm more of bone at the implant apex in order for the implant apex not to be exposed in the sinus.

The patient was really happy to have been done with this stage of surgery and she was really pleased how we helped her get through this as a team.

R.F., New York University College of Dentistry, Observation