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Over the past few months my classmates and I have been slowly honing our skills at admitting patients into the dental school and treating emergency patients.  This requires a medical and dental history to be filled out and then reviewed by us to help us know what the patient wants, needs and what thier limitations are.  There are not many medical issues that prevent us from providing dental treatment, but there are many conditions that require medications to control so that proper treatment can be performed.  Note that what we are taught in dental school is always different than what you do in private practice, so if there are any dentists who would like to chime in about the ‘real world’ here, make a comment below.  An example is in our emergency clinic.  Some patients present with a severe toothache but their blood pressure is so high (highest I have seen was a classmate of mine with a patient who had a BP of 210/120!)  Patients like this are referred either to the ER immediately or to their physician so it can be evaluated and treated properly with the correct medication.  Why?  High blood pressure can lead to complications during dental surgery.  To name the extreme issues, we are concerned most about a stroke or a heart attack.  No one wants a stroke while getting a tooth extracted.  Here is an interaction I had recently with an emergency patient:

ME: “So have you ever been hospitalized?”

Patient: “No, never.” (At this point some people move to the next question)

It is important to prod and pry a little. ME: “Do you have any kids?”

Patient: “Yes…”

ME: “Were you in the hospital for that?”

Patient: “[LOL] Yeah, I guess I was.”

ME: “Okay, have you ever been hospitalized for anything else?”

Patient: “Haha, yeah, I had breast reduction surgery.”

ME: “Hmmm, okay, were there any complications”

Patient: “No.”

What dentists typically look for are certain conditions like excessive bleeding or other conditions that would warrant a prophylactic antibiotic before any dental treatment is performed, such as a recent myocardial infarction, etc.  AHA guidelines for dental treatment.

I have searched for some other references on the web about proper medical health history taking and it’s importance:

• AGD article on why dentists prescribe medication (dumbed down a little so maybe you could use this to give to your patient)
• A concise guide on taking a medical history (just include a recent dental history as well)

I really couldn’t find much more. Which probably proves that it is more of an art form learned along the way rather than something you learn from the internet - like dentistry! Remember that taking a good medical history can catch many diseases and conditions that could halp the patients lifestyle and even save thier life.  The dental school sends many patients to see thier physician for something they didn’t know they had so it can be evaluated and treated.

In my quest to bring you everything good about dentistry I found a website giving away free samples.  Take a look:

http://zirc.com/samples.html

Comment back when you get something!

Clinic:
Over the past two weeks I have seen a few of my regular patients. I have about 4 motivated patients who show up to every appointment no matter what. The other patients I have picked up from the emergency clinic and they are a little less motivated. Most patients who go through emergency only come in when their teeth hurt and don’t care about their oral health when nothing is bothering them. I pick them up (get them assigned to me) in the off chance that I will get someone is is highly motivated to take care of the problems in their mouth. A few of these patients are really good and so far it has been worth it.

When a patient doesn’t show up for an appointment I head over to one of two clinics where you can get points without having your patient there - Emergency Oral Surgery or Pedodontics. Mostly I have been going to oral surgery because nothing is more fun than extracting a bombed out tooth. It takes quite a bit of skill - more than you would imagine. It is a challenge to take on some of the more ‘complicated’ cases which at this point most cases are complicated so everything is a challenge.

I had quite a few open appointments this past week and a half and have spent the past week in oral surgery. 3 of these days were duty days and the other days I just volunteered. I was able to do 35 extractions in about 12 days. There is no shortage of people who need a tooth extracted. Everything from a sore third molar (erupted) to a bombed out central incisor. SO far my favorite instrument is the lower cowhorn. If you have used it you know what I am talking about!

I have also been able to make it into perio a few times for some extensive subgingival cleaning with a cavitron and some aggressive scaling with the hand instruments. Perio can be annoying, but so far I like it. I don’t want to do it after I have my credits done but I like the challenge of finding the calculus on each tooth (know your anatomy!) and getting rid of it. All it requires is a heavy hand and a systematic cleaning of each tooth.

In operative I have been able to do a couple of things. In one appointment I sat back and watched the instructor do everything. There was some recurrent caries underneath an amalgam restoration and it looked radiographically very close to the pulp chamber. This was pretty much going to be a mechanical exposure so I was a little happy to let the doc take over and go for it. I was able to spoon excavate some of the decay though (really it was fun…) and when we were really close to the pulp chamber we stopped, placed a matrix band and filled it with IRM. This will be watched for the next month to see if the tooth can calm down (diagnosed as reversible pulpitis) and will later be restored. On the same patient a couple of days later I was able to do a DL composite on #11. The patient is treatment planned for 6 crowns and an upper and lower denture.

Today in the pedo clinic I showed up and volunteered. I had a patient assigned to me and I was able to treatment plan them for 10 sealants, a MIFL on #9, and a couple of 2-3 surface amalgam restorations. I will see them next week to start the treatment.

It has been busy, maybe not as busy as I would like, but when it is not busy I am able to head over to oral surgery or pedo clinic and get some points. Each clinic has a requirement for the number of points we need. If you reach a certain number then you get a ‘C’. If you get more, a ‘B’, and if you reach a certain number you get an ‘A’. Pedo requires 100 points with at least 25 of those being operative points for your Junior year to get an ‘A’.

Oral Surgery requires 75 extractions for the ‘A’ in your Junior year. I won’t have a problem in this clinic as I am up to 40 already and the majority of those in the past 2 weeks. I still need a lot of operative patients, endo patients and some more removable patients. It can be quite the hassle trying to schedule everyone and making sure you schedule a chair and also making sure you are getting your requirements done. It is well worth it though and very fun to be in the clinic. More to come!

Dental Student FORUM:
Make sure you join the forum and start asking questions or post your thoughts! I know SDN has a huge monopoly, but I think we can do a better job at making information more available online! Login, post, and tell your friends!

COMING SOON:

Here are the details and let me be the first blog to welcome Dr. Ismail to Temple!

Temple University has named Amid I. Ismail, BDS, MPH, MBA, DrPH, and diplomate ABDPH, a passionate advocate for the underserved and an international expert on dental health disparities, dean of the Maurice H. Kornberg School of Dentistry effective October 13, 2008.

Ismail joins Temple from the University of Michigan in Ann Arbor where he is professor of health services research and cariology at the School of Dentistry and professor of epidemiology and director of the program in dental public health at the School of Public Health.

“Dr. Ismail is a highly regarded educator, researcher and clinician who shares Temple’s fundamental value of service to others.  He will be an effective academic leader and a champion of improved oral health for our community,” said Temple University President, Ann Weaver Hart.

Throughout his career, Ismail has spurred collaborative programs and research projects to better meet the needs of society’s underserved populations, particularly Mexican-Americans and African-Americans.  In Detroit, he has led two such initiatives, both funded by the National Institutes of Health: the five-year, $1.6 million Detroit Oral Cancer Prevention Project, and the seven-year, $6.9 million Detroit Center for Research on Oral Health Disparities.  He was also the principal investigator of a $6.9 million NIH grant to study a Web-based resource on evidence-based dentistry.

“Dr. Ismail’s vision for integrating education, research, service and dental care will propel the school to the forefront of urban academic dentistry, and serve as a model for others,” said Lisa Staiano-Coico, Temple University Provost.

A consummate leader, Ismail has held positions of stature at numerous professional associations. Currently chair of the American Dental Association’s (ADA) Curriculum Development Committee of the Community Dental Health Coordinator program, he formerly chaired the ADA Council on Scientific Affairs and the National Affairs Committee of the American Association for Dental Research.  He has also organized and co-organized several national and international conferences that led to major changes in evidence-based health care and dental practice, including the NIH Consensus Conference on Dental Caries Management Throughout Life and the ADA Clinical Recommendations Panels on Fluoride Supplements and Professional Topical Fluoride.  Additionally, he has been active in the ADA’s Dental Economics Advisory Committee and the Division of Science, and co-chairs the Coordinating Committee of the International Caries Detection and Assessment System.

Ismail received his dental degree (BDS) from the University of Baghdad. Prior to joining the University of Michigan, from which he earned an MPH, a DrPH, and later, an MBA, he served on the faculties of Dalhousie and McGill Universities in Canada.

Ismail is a prolific scientist, having published and presented over 200 abstracts, manuscripts and editorials, and co-authoring the chapter, “Dental Care Delivery System,” in the Surgeon General’s 2000 landmark report on Oral Health.  His work, focused on oral and overall health issues facing the underserved, such as cancer risk, depression and diet, has appeared in such scholarly journals as The Lancet, the Journal of the American Medical Association, the Journal of the American Dental Association, and Pediatric Dentistry.

“I’m thrilled to be joining Temple University and the Kornberg School of Dentistry and plan to work with and for the faculty, students, staff and alumni to develop a new urban academic dental education model to prepare dentists with advanced clinical skills and knowledge of current health policy and management methods,” said Ismail.

“Differences of opinion will be welcomed and encouraged, and I will foster a transparent, caring and learning environment at the dental school,” he continued.

Among Ismail’s priorities is building collaborations with alumni.

“Dental alumni are a major resource with extensive experience in dental practice and managing the business of dental practice. Their expertise will be sought after frequently during my tenure as dean,” he said.

The Kornberg School of Dentistry, founded in 1863 and the second oldest U.S. dental school in continuous operation, fills a critical need in Philadelphia and the region, supplying highly qualified dentists and providing dental care to the community. Situated at the Health Sciences Center among the Schools of Medicine and Pharmacy, the College of Health Professions and Temple University Hospital, the dental school offers a rigorous curriculum known for its excellence in clinical preparation.  Under the direction of Temple faculty, dental students perform close to 300,000 procedures annually, making it one of the busiest academic dental clinics in the country.

We have been in school for a week now and already I feel slightly overwhelmed with everything going on.  Let me break it down for you:

Classes:

• Radiology II
• Oral Surgery II
• Oral Pathology II
• Endodontics II
• Restorative Dentistry V
• Medicine II
• Periodontology/Treatment Planning

We have just started and there is a fair amount of reading so far.  RD V is basically reading a lot of current articles in dentistry.  Lots of publications and research articles about dentistry.  The ‘classics’ if you will of dentistry.  Oral Path is covering the other half of Neville’s Oral Pathology book that we didn’t cover the first time in class and is taught very well.  It includes differential diagnosis workshops and enough disgusting pictures to last a lifetime.  The other classes are pretty much self explanatory.  It will be busy with this classes alone.

Clinic:

• Open to Juniors on M, W, F with two time slots each day.  8:30 to 11:30am and 1:30 to 4:30pm.  With 125 Juniors and 125 Seniors all vying for a spot - it can be a headache at times getting a chair.  Especially in limited chair clinics like Tx Planning and Perio.  The way it works is this: Every afternoon at about 4:30pm new time slots open up 7 days in advance.  First come, first serve.  So if you want a chair in perio, 7 days from now, you will have to wait until the system opens the chairs up at 4:30pm TODAY and then reserve your chair for SEVEN days in the future.  Lots of dental schools do it this way.  Some dental schools open the chair reserve time at 6am.  I would rather stay at school and reserve a chair than wake up early and drive to school to get a chair.  I am curious as to what other schools do?  I know the best way is to have YOUR OWN chair and schedule your life away at your own accord.  Maybe Temple is headed in this direction?  I doubt it, but it could very well be done with some patience and good leadership.
• I have about 15 patients right now and feel slightly overwhelmed.  Everyday I am learning something new that improves my general knowledge (this task is easy to accomplish), improves my skills, or improves some other aspect of dentistry in which I am lacking.  The key is to not get too comfortable.  If you get too comfortable it means you are not moving forward.  Right now I have a lot of patients in Perio.  Some items in the treatment plans of my patients are extractions, crowns, removable partials and full partials and some cavities that need to be taken care of.  I should be bus for a while with these patients.  We have a lot of requirements to do at Temple and these patients will only wittle away at the amount, but I think it is a good start.

Clubs:

• It is fun to get involved in clubs at your school.  I wrote about the Haiti Club I am involved in a few days ago.  I am also a part of the Oral Surgery Honor Society as co-treasurer, I am a part of the practice management club, a member of XIP fraternity, and a member of the ADEA committee of continuing education.  It does take a little time but overall these are rewarding experiances which allow me to interact with other students and get away from the hustle and bustle of trying to get A’s all the time.

Family

• Yes, I am married.  We both have busy lives and it is nice to go on a date once a week on Friday night to hang out.  My wife stays home with our two pets boys most of the day and does a wonderful job.  We have two boys age 4 and 3 who think that life is thier little playground.  They are good at wrestling me to the ground when I come home from school and making messes.  They keep me grounded - which is a good thing because sometimes I come home from school with a skewed viewpoint of what is important (like being called a ‘dumbsh#@’ during treatment planning) and they help me to see what is REALLY important.  For instance:  Everything makes better sense when you come home from a frustrating days work and you find a letter on your study desk with a coloring page of Optimus Prime and He-Man in action poses next to each other and a goofy signature in the corner of the page from your 4 year old.  No professor can ever defeat that.  I would love to see Dr.” ______” take on Optimus Prime and He-Man at the same time.  Treatment plan that outcome

All in all it should be a fun year with lots of fun things going on and a lot to learn.  Remember that I will try to post cases online (if I am legally able to do so) so you can follow my various adventures in the clinic.  Have a good year and stay motivated!

Please pass the word along!  If you have a website would you mind giving the following post a short plug? Thanks!

I am part of a club at Temple University Kornberg School of Dentistry that sends 9 students to Haiti once a year as part of an outreach group to provide dental care to impoverished Haitians. The Haiti Club has been around for several years now and I have had the honor of building the clubs website. (You’ll notice it looks a lot like my website).

During this trip which lasts for one week over 1,000 Haitians are treated. There have been a few instances where the outreach group have been able to treat severe odontogenic infections which left untreated would have resulted in death. It is a life changing experiance for faculty, students and the natives who benefit from the trip.

My plug is to basically ask for donations to the outreach group. 100% of the proceeds goes to fund the trip, there is NO skimming off the top. Rest assured that every dollar donated is a dollar well spent and no pockets are padded. The club works in affiliation with the Haitian Health Foundation, a legitimate charitable organization. Please take the time to check out the website, view photos of past trips (more pics coming soon), and then donate.

Every donation is tax deductible and after you donate a TAX ID number will be sent to you! You can use this number when you claim your taxes. The club is registered as a charitable organization and is official.

I do not benefit from this in any way, shape, or form. The cause of the group has become something I enjoy and have therefore donated my time and effort into doing this. These people have next to nothing and a little bit goes a long way. Thanks for helping!

Note: This is a quick reference review for the management of coronary artery disease (CAD) which causes stable angina, unstable angina, and myocardial infarction. The article also assumes that the reader has a background knowledge in medicine. This article was written by a dental student using notes and textbooks as references. Please feel free to comment with any suggestions or changes. This article is intended to be used as a reference. If you are experiencing any of these symptoms please consult a physician.

Coronary artery disease is usually characterized by substernal chest pressure.

Risk factors include smoking, high BP, diabetes, hypercholesterolemia, stress, anxiety.

Symptoms include chest pain in the form of ache, pressure, squeeze, a heavy feeling, palpitations, and syncope. There are few signs to look for unless CAD is accompanied by cardiac heart failure.

Underlying diseases include HTN, hyperlipidemia (xanthoma), and diabetes (retinal changes).

Lab findings of the following can contribute to or worsen CAD: anemia, hyperthyroidism, diabetes, lipids, homocysteine, and C-reactive protein (CRP).

There are various cell markers that can indicate CAD. Myocardial specific cell markers include troponin I, troponin T and these show up about 3 hours post injury. A trauma specific cell marker includes creatine kinase (CK-MB).

Diagnosis is done by EKG, chest xray, echocardiography, cardiac catheterization and angiogram. A stress test can be performed: nuclear injection -> perfusion -> exercise -> Bruce-Protocol and EKG.

Stable Angina is predictable and for the most part constant. Think of it as a ‘99% blockage’. Treatment includes treating associated diseases, decreasing risk factorsand lifestyle modifications. Likely medications include NG, long lasting nitrates, antiplatelets, beta blockers, CCB’s, and ACE inhibitors. Patients may also have undergone revascularization surgery such as angioplasty - stents, coronary artery bypass graft using mammary arteries or saphenous vein.

Dental treatment of MI >1mo: AM appointments, comfortable chair position, vital signs, NG on hand. Stress reduction in the form of communication, oral sedation, nitrous, and good local anesthesia for pain control.

• limit epinephrine to 2 carpules of 1:100,000 epinephrine
• avoid retraction cord w/ epinephrine
• excellent pain control
• avoid anticholinergics (scopolamine/atropine)
• patients may be on an aspirin regimen - keep them on aspirin but be prepared to control the bleeding.

Unstable Angina is a new changing pain at rest. Results from a small plaque that ruptures (not a 99% blockage) and blocks or occludes an artery suddenly. Avoid elective care and get a consult from a physician. There are no oral manifestations but there may be pain in the lower jaw and lower teeth which can be a symptom of abnormal angina. Drug related signs may be xerostomia, taste change, stomatitis, and bleeding (anticoagulants). Patients may be on nitrates, BB’s, CCB’s, Ace Inhibitors, statins, and aspirin.

Dental treatment of MI <1mo: Defer treatment until patient is stable. In an emergency such as pain, infection or bleeding prophylactic NG can be given. Consider an IV line, sedation, oxygen, EKG and pulse ox. Caution should be used with epinephrine. Carbocaine (mepivicaine) is a better alternative because it has no epinephrine.

Acute coronary syndrome is a term used to encompass clinical symptoms associated with a MI. Patients should be taken to the hospital immediately. Early treatment includes chewing aspirin and an anticoagulant (heparin/LMWH).

Other facts:

• Ischemia can be seen on an EKG as a T wave inversion
• Acute MI can be seen as an ST elevation (greater than 4mm) and should be treated immediately.

I was going to commit myself if I had to study for another minute. My eyes were going cross eyed all by themselves because I had been reading so much. I studied about 4 hours a day for the first month, then boosted it up to 6 hours a day for a couple of weeks and then 12 hours a day for a week. Then I was so BURNED out that I stopped studying for three days before I took the test. I reviewed a little dental anatomy the day before the test. We also had three classes during this time (finals are next week), add patients and duty days in the clinics and my extracurricular activities and family (who were largely ignored for 2 months) - It has been fairly busy. I was a little disappointed in the test though. It was in almost no way similar to any back test I took. More on this in a minute, here is how my studies went.

I started with Dental Decks. These are a great resource for a number of reasons. They are a good review. Even now, i could pull them out and learn something new. I think in future months I will sort through them and find the ones that are most pertinent [Read more →]

This one is all the abdominal retro peritoneal viscera: Ursula Uses Kids to Deliver All Lemon Pies except Sue’s Tasty Crust

• Ureters
• Urinary bladder
• Kidneys
• Duodenum (2nd/3rd parts)
• Adrenal glands
• Large intestine
• Pancreas (head and neck of)
• EXCEPT (not retroperitoneal)
  • Sigmoid
  • Transverse
  • Colon

Others include: esophagus, rectum, bladder, uterus, aorta, inferior vena cava.

Any more?  These will be on boards!

I wrote this article a couple of months ago after my first experiance in our oral surgery clinic.  I am a little burned out on studying for Part I of the National Dental Board Examination (NBDE Part I) so I decided to edit it a little bit, add to it and post it for your entertainment:

Last week I had three straight days of oral surgery duty followed by a day in the elective oral surgery clinic for a patient of mine who had about 16 retained root tips. It really was very educational, exciting, and challenging. Here is how the days went:

Day One:

We met for a short half hour lecture with about six other classmates and went over the basics. We met around a small table and reviewed the various surgical instruments and steps to properly extract a tooth. We have had two oral surgery classes taught thus far and I thought they were taught well, so this review was minor. Various things like how to load a needle and carpule, how to use the periosteal, elevators, and forceps and proper extraction techniques.

After this we paired up with a senior, grabbed a chart and sat our patient. Our duty days at Temple in the OS department covers all the emergency pain of walk in patients. Some of the patients get referred to emergency endodontics and some get their pain treated on the spot by those in the OS duty department - via an extraction. It really is quite stream lined and simple. The patient is seated and the medical history is reviewed. You ask them about their chief complaint (why are you here), and the history of the complaint. Example: The patient comes in because their tooth is hurting. Where does it hurt? Is is in one spot or all over? Can they point to it? What causes the pain? Does it get worse with something (like cold/heat/sweets), or does it get better with something (like cold/heat). How long have they had the pain? Is it continuous or spontaneous? Does the pain keep them up at night? Various other questions can be asked to get a good background.

The medical history is then reviewed. Anything that they have indicated on their medical history form and a history of family health problems, allergies, hospitalizations, medications and anything else that could effect their treatment such as a complication from a previous surgery.  At this point we are looking for contraindications or anything that will hinder our procedure.  The more prepared you are before the extraction the lower the chances are of a complication arising AND if such a complication were to ocur you will be better able to handle it.

Blood pressure is taken, along with a pulse and then a clinical exam is done. This is where you actually look into the mouth and have a look at what is going on. Most of the time you can see right away which tooth is causing them pain. It is pretty easy when a huge gaping black lesion is staring back at you when you look at the teeth. Sometimes it isn’t as easy. Tapping on teeth, palpating, using endo ice, etc can help you to pinpoint the tooth in trouble.  When the culprit has been found then you present various options to the patient depending on what you think can be done for the tooth.  If the tooth is absolutely bombed out then an extraction is most likely indicated.  Sometimes the tooth is still in good shape and it needs a root canal.  If this is the case we refer them to emergency endodontics and seat the next patient.

In my first four days of duty and my elective appointment I was able to extract about 20 teeth.  A few anteriors, some premolars and a few molars.  Many of those were from the 16 retained root tips from my own patient - which added up to about 6 teeth.  Some were difficult and some were easy to extract.

The first tooth was a right canine covered with the thickest canine eminence I have ever seen.  It took quite a bit of time to get it just a little loose.  Even then the crown broke (not by me, lol) and in the end our instructor had to come over and show us how a real doctor does an extraction.

I think the biggest hurdle to overcome while starting in the clinic is to go quickly and not stop each time the patient whimpers.  During my first appointment I was so worried about not hurting the patient that every time he moaned a little bit I would stop and ask him how he was doing.  This added to the time it took to do the extraction.  I KNEW he was numb - we dumped a whole carpule of articaine right into the pulp chamber - (he is probably still numb), but I was still a little hesitant.  The trick is to learn how to be aggressively finesse, if that makes sense.  At Temple to get an A during your junior year 75 teeth are to be extracted.  As a senior you have to reach 125 teeth.  This includes alveoplasties, the removal of tori, and other minor OS procedures.