Guide to Clinical Procedures

Page 1

lay down the law before you give them the appointment. And you don't have to give them your fIrst available appointment. You can schedule it a few weeks out.

CONFIRM YOUR APPOINTMENTS I recommend calling your patient the day before the appointment to confIrm the appointment. Don't think that this is annoying to the patient: most patients really appreciate it. Very few patients find it annoying. And I know it's a hassle to confmn your patients. You have too much stuff to do already, you don't need more stuff. But if you confIrm your patient, you'll have less missed appointments. It's as simple as that. How bad do you want your patients to show up?

DENTURE PATIENTS You need to ask them certain things.

Do you have any pain with anything in your mouth?

Do you have any of you natural teeth left? Which ones?

Have you ever worn a denture before?

Do you currently wear a denture? How do you like it?

You need to tell them certain things. Maybe you don't have so say everything in the fIrst phone call, but you should say all this and more during the diagnosis appointment. You should cover everything in great detail during the diagnosis appointment. Of course what you tell them depends upon what they want: partial or complete dentures, conventional or immediate dentures. This is what I might say for someone who wants conventional complete dentures and has their natural teeth.

At the dental school, we work really hard to make your dentures, but it'll take a lot of appointments.

It takes 2 or more appointments to remove the teeth and 7 or more to make the dentures.

Once your teeth are out, it takes 2 months for your mouth to heal. And it usually takes two months

to finish the dentures. During this time, you won't have teeth. That's the timeframe we're looking

at.

Dentures aren't real teeth. They feel different. And when you eat or drink or talk, it's different, and

it takes some time to get used to it.

Most people like their top denture, but the bottom denture moves around a lot. We can place

implants that'll help keep the lower denture in place.

I also give them a piece of paper on how to take care of their new denture. I know they're not getting a

new denture, it's only the diagnosis appointment. But there's a piece of paper that we give out when

patients get new dentures, and it talks about what it's like having a denture and the things you have to do.

It would be a great idea for the patient to read this now. They'll have a better idea on what to expect.

There's probably more stuff you should tell them, ask your denture teachers about it. I'm not a denture

expert, I don't know.

GIVING ESTIMATES

It's polite to estimate the cost of the appointment before hand. It's also essential to emphasize that it's just

an estimate. I use the word guess. You don't know for sure what will happen.

A small fIlling can turn into a large fIlling.

A filling can turn into a root canal.

A prophy can turn into SRP.

You can plan to do an MO on #13 and discover a DO on #12 in the process.


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WHY YOU NEED A CROWN Why do you crown a tooth? To give the tooth extra protection against fractures. CROWN = PROTECTION FROM FRACTURE. Patients frequently don't understand this. They think you only need a crown if the tooth breaks: CROWN = WAY TO SAVE THE TOOTH AFTER A FRACTURE. You should be able to explain the benefit of a crown to the patient. Here's a way to do it. This tooth is weak. Filling to big, there's a craze line, tooth had endo, etc There's a risk this tooth will fracture. Bite down on a cherry pit or a bone, bite just the wrong way, the tooth may break. It might not break. There's about a 50/50 chance. If the tooth does break, we mayor may not be able to save it. Sometimes it's easy to save the tooth. Sometimes it's very hard and expensive to save the tooth. And sometimes we can't save it, the only thing we can do is remove the tooth. Putting a crown on the tooth will protect the tooth from fracture. It lowers the chance of a fracture. And it increases the chance of you keeping that tooth until you're a little old man. If you're willing to take the risk, you don't have to get a crown. If you want the protection and the peace of mind, you should get the crown. Getting a crown is what I recommend. If you were a member of my family, that's what I'd do for you. When you decide that you're ready to put a crown on that tooth, just give me a call and we'll set up an appointment. .

HAVE CONFIDENCE Do you feel like you're not ready for clinic? Are you scared to give injections and do fillings? Do you feel like the dentistry you do isn't very good? Do you lack confidence? It's ok, a lot of people feel that way. The best way to get confident is to do it a lot. That doesn't apply to you at this time. The next best way to get confident is to prepare very well. Think about your patients the day before. Think about all the steps to each procedure. Figure out what instruments you need and where do get them. Then you've done everything you could to get prepared. Then when the patient comes and you get stuck, you have all sorts of people here to help you. Just tell the patient I'll be right back. You don't have to say why. Do don't have to say I don't know what to do or I got stuck. You could just say I want to get a second opinion on something, or I want to show my teacher something. If you're working on a patient, never say Oops or Whoops. And if you don't understand something, it's ok to ask the teacher, but don't do it in front of the patient.

PROBLEMS Taking x-rays is a problem. For the first 2 weeks, everybody needs x-rays. There aren't enough x-ray machines or x-ray cubicles. You aren't allowed to take x-rays until you've had your radiology rotation. So you have to fmd someone to take x-rays for you. And then you have to wait in line. And then sometimes the software crashes. It's a hassle. How do you explain it to the patient? Blame it on the dental school. Just say there's not enough x-ray cubicles. There are long lines. And why can't you take the x-rays? The dental school doesn't want me to take the x-rays, it wants other people to take the x-rays, and I have to respect the rules here.

~

Another problem is everyone is doing diagnoses at the same time. It takes a teacher forever to check a diagnosis. So you'll have to wait on teachers for a long time. And you'll have to explain this to patients. Another problem is everyone needs to treatment plan right away, and there's not enough treatment planning appointments available.


Predoctoral Clinic Fee Estimate for Screening Process

Effective October 1, 2007

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$36.00

$76.00

Initial Diagnosis Fee - \~ ~VY'\

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$53.00

$110.00

Radiographs (X-rays-FMSlPano)

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$167.00 $201.00 $242.00

$740.00 $875.00 $875.00

Endodontics (Root canal): Endodontics (Root canal): Endodontics (Root canal):

$20.00

$45.00

Sealants

$117.00 $150.00 $183.00 $215.00

Amalgam (Silver filling): Amalgam (Silver filling): Amalgam (Silver :filling): Amalgam (Silver filling):

$139.00 $171.00 $213.00 $267.00

Composite anterior (footh colored front tooth filling): Composite anterior (footh colored front tooth filling): Composite anterior (footh colored front tooth filling): Composite anterior (footh colored front tooth filling):

One surface Two surfaces Three surfaces Four surfaces

$46.00 $79.00 $102.00 $114.00

$152.00 $199.00 $250.00 $300.00

Composite posterior (footh colored back tooth filling): Composite posterior (footh colored back tooth filling): Composite posterior (footh colored back tooth filling): Composite posterior (footh colored back tooth filling):

One surface Two surfaces Three surfaces Four surfaces

$152.00

$300.00

Bleaching (single arch)

$191.00$318.00 1:,. ""

$548.00$935.00

Veneers

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$53.00 $65.00 $78.00

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$46.00 $59.00

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$64..00

\S50.00J 34.00 $65.00

'r"t\+. $90.00

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$243.00 $430.00 $256.00 $387.00

$76.00 $76.00 $220.00 '$45.00 $654.00 $950.00 $945.00 $985.00

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Single Canal Two Canals

Three Canals

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Erupted/nonsurgical extraction oftooth 'f...- "'"'f <.> Full bone impaction oftooth extraction oftooth

Alveoplasty (bone contouring) with extraction per quadrant

Alveoplasty (bone contouring) with extraction per quadrant

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Adult prophylaxis (cleaning)

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Re-evaluation and deplaque Periodontal flap surgery (gum surgery) plus $15.00 per additional tooth flap surgery/crown lengthening

ri)\plllnt~ J51 Crown (Cap) Pontic (footh replacement in cemented bridge) ~ (Olo Ceramic crown (Tooth colored cap) "'2.. Implant restomtive parts -{ J"1 I Endosseous implant (surgery and implant not including crown) , ,

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$1,485.00 $1,581.00 $1,552.00

Complete denture (per arch) Immediate denture (per arch including one rebase or reline RPD (removable partial denture per arch; cast framework)

tSchool of Dentistry cost for treatment 2Usual and customary fees in private practice.

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DIAGNOSIS APPT [SETUP] CSR: BOE, trays; bite forks DISP: gun/regisilJadhesive, anesthetic for probing, home care kit TEAM: PPE, cart CUBE: CMS login, items in tx plan, approved, pull up x-rays, untangle hoses, dust signature pad TEAM: blue napkins, head covers & tape, wrap (light & switch, keyboard, buttons & handle) TEAM: gauze/cotton rolls/applicators, suction tips, mask CUBE: 3-way, alginate, napkin chain, check cups/napkins TEAM CART: Scope; regisil tips MY CART: gloves, alginatelbowls/cylinder, facebow; floss, cup holder, spatula/timer; safety glasses, mirror, BP cuff; loupes

[PROCEDURE] The proper order for screening pt is: screening note, assign doctor, activate pt, sign in Take BP/premedlblood sugar Patient approve tx plan Sign in, check/modify/approve tx plan, order radiographs Take radiographs Health history, medications, sign off on both Put on masklloupeslgloves, put on glasses & bib, oral exam, halfway check Charting, add new chart, figure out which teeth are there & which are gone Restorations: general look, bite down and look, dry teeth & check 1) RESTORATIONS: amalJcomp/seal, crownlinlay/onlaylbridge/implant, CDIRPD 2) RESTORATION DEFECTS: open margins, fractures, overhangs, open contacts a. Is defect causing caries or perio problem (bleeding/attachment loss/deeper pocket)? b. Is it cleansable? Is it a food or plaque trap? c. Can I do better? (Gingival margin way gingival, large interproximal space to fill) d. What are the patient's desires? Can we or have we been watching the restoration? 3) CARIES: sight, explorer, transilluminate, IP on radiograph 4) OTHER: abrasion, fractures, cracks, missing cusps 5) POSITION: displaced, tipping, rotation, diastema, crossbite 6) RADIOGRAPHS a. Apexlfurcation lesions, lamina dura, ROOT CANAL TX, root caries b. Bone level, calculus c. IP caries, root caries, other caries d. Restorations (C&B, fillings), overhangs, open margins e. Implant, post, pins, amalgam pins CARIES RISK ASSESSMENT Perio: probing, bleeding, recession, mobility, furcation PERIO CASE TYPE Print graph, tx notes, get print out & faculty Faculty checks diagnosis, makes notes Take impressions Disclose, record plaque, show pt plaque Sign out, pt to cashier, pour up models


ENDOAPPT [SETUP] CUBE: CMS login, items in tx plan, approved, pull up x-rays TEAM: blue napkins, head covers, wrap; cotton, suction tips, mask; PPE, cart TEAM CART: Scope, LA tip, rubber dam, ethanol MY CART: topical, floss, torch GENERAL: BP cuff, safety glasses, mirror; gloves, loupes; cup holder Double check kits: fmger spreader, gutta percha

CSR ENDO SETUP: SS, HS, endo handpiece, endo bur, endo extripate kit (21/25/31), endo fill kit, rubber dam EXTRA: Op kit, op bur, fixed bur, bite block

DISP ORDER: Apex locator, ligajet, articaine, system B, obturalcalamus EXTRlPATE: Endo disposable kit, apex locator, LA, Articaine/ligajet, EPT Disposable kit: bleach, EDTA, lube, cavit, sterile cotton, points FILL: Endo fill kit, system B, obtura, LA Comp temp: comp kit, comp gun, light tip

Do you think it's restorable?

Find pt's desires, fmandal resources, time resources; know estimate offees for pt

Endo diagnosis

Anesthetic

Rubber dam (don't let clamp get in the way)

Remove caries

Team faculty verifies restorability

Get working length from x-ray

Find chamber

Make access w/round burs and LA access

Check patency with endo explorer and patency file (bleach?)

Use apex locator to determine WL (subtract 1 mm?)

Verify WL wi x-ray (what size file, 30?), adjust WL as needed

Pattern: Bleach, patency file, lubed working file

3510.12 on handpiece, no torque converter (5 mm short ofWL?)

30/0.06 to WL (it went down wino resistance)

40/0.06 to WL (a bit of resistance, filings), good shaping objective, master file

Bleach real good, rinse(?), dry with paper points

Choose master cone

Master cone should be a 40 (master file), there should be tugback (good apical control zone)

Fit 40 cone, no tugback, gotta think fast, cut a 0.06 taper cone to 50, cone is it's own stop

Take master cone x-ray

Pick tip for System B: want tip 5mm from apex(?), set stopper, 40 + 5mm * 0.06 = 70, tip smaller than 70

Pick hand plugger

Setup System B, set up Obtura

Dry canal again(?), bleach cone(?)

Mix sealer, apply sealer with something(?)

Coat master cone wlsealer, insert, condense w/System B

Backfill w/Obtura


Take fmal film (temporize first?)

Clean up GP, temporize, take tooth out of occlusion

[PREP]

Sign in: pt consent, BP cuff/stethoscope, pt goggles Topical, place LA, take shade Choose tooth to clamp, choose clamp, ligate clamp, punch dam Place rubber dam, slow suction in mouth Maybe pre-wedge Ideal prep, remove caries [CLEANUP] Cut away rubber dam, rinse pt well


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EXAM AND PROPHY APPT [SETUP] CSR: BOE, trays, prophy kit, slow speed, cavitron inserts DISP: HOME CARE KIT, prophy jet, anesthetic, floss/super floss/floss threader TEAM: PPE, cart CUBE: CMS login, items in tx plan *OID*, approved, pull up x-rays, untangle hoses, dust signature pad TEAM: blue napkins, head covers & tape, wrap (light & switch, keyboard, buttons & handle) TEAM: gauze/cotton rolls/applicators, suction tips, mask CUBE: handpieces & 3-way, napkin chain TEAM CART: Scope, disclosing agent, prophy paste, prophy angle, LA tip MY CART: gloves, alginatelbowls/cylinder; topical, floss, cup holder, spatula/timer; safety glasses, mirror, BP cuff, cavitron; loupes

[PROCEDURE] Take BP/premedlblood sugar Sign in, check/modify/approve tx plan, order radiographs Take radiographs Health history, medications, sign off on both Put on mask/loupes/gloves, put on glasses & bib, oral exam Charting, add new chart, figure out which teeth are there & which are gone Restorations: general look, bite down and look, dry teeth & check 1) RESTORATIONS: amal/comp/seal, crown/inlay/onlaylbridge/implant, CD/RPD 2) RESTORATION DEFECTS: open margins, fractures, overhangs, open contacts a. Is defect causing caries or perio problem (bleeding/attachment loss/deeper pocket)? b. Is it cleansable? Is it a food or plaque trap? c. Can I do better? (Gingival margin way gingival, large interproximal space to fill) d. What are the patient's desires? Can we or have we been watching the restoration? 3) CARIES: sight, explorer, transilluminate, IP on radiograph 4) OTHER: abrasion, fractures, cracks, missing cusps 5) POSITION: displaced, tipping, rotation, diastema, crossbite 6) RADIOGRAPHS a. Apex lesions, lamina dura, ROOT CANAL TX, root caries b. Bone level, calculus c. IP caries, root caries, other caries d. Restorations (C&B, fillings), overhangs, open margins e. Implant, post, pins, amalgam pins CARIES RISK ASSESSMENT Perio: probing, bleeding, recession, mobility, furcation PERIO CASE TYPE Print graph, tx notes, get print out & faculty Faculty checks diagnosis, makes notes Take impressions Disclose pt, record plaque (CARIES RISK, PERIO CASE), OHI (show pt plaque & how to brush) Remove calculus & sub-G plaque with cavitronlhand instruments Floss teeth Check calculus & sub-G plaque removal with explorer & gauze/air syringe/mirror Polish teeth with rubber cup/prophy jet, rinse pt Floss to get prophy paste off, rinse again Disclose again to see if you've missed anything (optional) Faculty check plaque removal (optional) Fluoride tray Faculty check prophy, sign out Pt to cashier, pour up models


FIXED CEMENT APPT [BEFORE APPT) Get crown and casts from lab Evaluate contacts, margin, and occlusion on the mounted/sectioned cast Evaluate contacts and margin on the rigid cast

[SETUP] TEAM: PPE, cart TEAM: blue napkins, head covers & tape, wrap TEAM: cotton, suction tips, mask, ALCOHOL CUBE: handpieces & 3-way, napkin chain, anesthetic CSR: op/fixed kit & burs, SS/HS, eX1raoraliintraoral gold polishing burs, porcelain polishing? DISP: cement (eg RelyX), glass slab, fit checker, accufilm, student polishing kit, concept scrub? GENERAL: LA, wood stick, light tip? TEAM CART: pumice, rubber prophy cup, scope, LA tip MY CART: crown & casts, articulating paper/shimstock, mixing pad, topical, floss wlknot, curing light? GENERAL: BP cuff, safety glasses, mirror; gloves, loupes; cup holder

[PROCEDURE]

Check which teeth occlude and which don't, check both sides

Remove provisional with spoon and throat pack

Anesthetic if needed (most people don't need anesthetic)

Clean off all the cement with scaler and rubber cup/pumice (or use Concept Scrub? Skaggs mentioned it)

EVALUATE/ADJUST CROWN

Don't forget throat gauze, double check orientation of crown 1) Evaluate shade 2) Evaluate proximal contacts (if it's like hammock, polish down, use Accufilm to determine where) 3) Evaluate internal fit (use Fit Checker, look for perforations) 4) Evaluate margins (use pigtail explorer, take BWX) 5) Evaluate occlusion of other teeth (crown in vs crown out: grab shimstock, paper marks same) 6) Evaluate occlusion (use articulating paper, ask pt if it feels high, check centric and excursive) Polish (brown/green/super green Shofu points OR green/white stone, tripolee, rouge)

Alcohol inside of crown with Q tip, dry crown

Microetch if needed (if you used Fit Checker or you need to clean off old cement)

If crown is not satisfactory, make more impressions

CEMENT CROWN

Once again, check contacts, margins, occlusion (if you adjusted a lot)

Clean marks off of adjacent teeth

Pumice tooth, rinse away pumice, isolate/dry with suction & lots of cotton

Assistant mixes cement (3 scoops/drops RelyX, loads cement halfway, gets it all around the margin)

Doctor practices inserting crown to get orientation right, have hemostats ready in case of mis-seat

Insert crown, push hard with froger, pt bites down hard on cotton roll/wood stick, get it seated all the way

Determine if crown is seated all the way: check margins w/explorer, marginal ridge height, occlusion?

If crown is not seated all the way, pull it off right away before the cement dries

If seated ok, have pt bite softly for a few minutes (they don't have to bite hard)

Clean off cement frrst with explorer, not floss yet (cement isn't fully set), wait for full set

Clean off cement with pigtail explorer/floss, use floss with a knot in it for cleaning interproximally

Check contacts, margins, occlusion, ask pt if it feels high, adjust if needed

Have some sort of post-cementation talk


FIXED PINDEX IN LAB [SETUP] CSR: slow speed, high speed, op burs DISP: mounting plates, anterior guide table CART: superglue, scalpel, pineapple burs, bowl, spatula, torch, lighter, buffalo knife, red pencil LOCKER: boat base, saw, new blade LAB/TEAM: pins, sleeves, wax; medicine cup; wood sticks, green stick

[PROCEDURE] POUR IMPRESSION Make the model easy to separate and easy to trim! Trim extra VPS off of impression Use orange spray, air dry Wrap wax strips around impression (maybe) Gather supplies: vaccu-spat, hose, water syringe, stone (bag), scalpel to cut bag, little spatula, big spatula Find a vacu-spat and vibrator that work, are close, and nobody is using, hook up hose, get stuff over there Put water in vacu-spat, open stone, mix stone, pour impression Wait a few minutes and put stone turd on impression (maybe) Wait I hour before separating BEFORE BOAT Smooth model, flat bottom & sides (remove undercuts that lock into the boat) Size up the model in boat base, trim model if it's too big Plan cuts & pins & notches Practice drill on scrap model, drill, bur notch (lingual), scalpel notch (buccal) Try pins in hole, try sleeves on pins (don't use tight pins) Vasoline die, cement pins, vasoline pins, sleeve pins, wax balls/strips Mix a lot of yellow stone, put stone on pins, fill boat base, push die in hard, fill bur notches Get all the extrarllow stone out of the lingual part of the model, we don't care bout the buccal You can pour 2n impression while the boat is drying, 45 minutes for boat to dry Section first or mount first? I prefer mount first, teeth might touch better on the articulator MOUNT Trim boat, separate die Check models: bubbles, distal distortion, anterior distortion, regisil bite registration, teeth touch? Stick down model Check articulator: condyle screws tight, pin set at zero, mounting plates down tight Mount (middle of model in middle of articulator, occlusal plane level, make it look believable) Rubber band on articulator, wait 1 hour, afterwards check occlusion with shimstock, remount if bad SECTION & TRIM DIE Section die (perpendicular cuts, avoid pins, avoid margins) Trim die with handpiece and scalpel Mark margin with red wax pencil


FIXED PREP APPT [BEFORE APPT] Fill out blue card Plan crown: FGCIPFMlPJC, shade, metaVporcelain design, opposing dentition, canine guidance/group fx 2 custom trays (or plan for stock trays): cast, silly putty, TRIAD Practice crown prep: high speed, slow speed, fixed burs, op burs, fixed kit Pt must pay for crown before lab takes it [SETUP] TEAM: PPE, cart; blue napkins, head covers & tape, wrap; cotton, suction tips, mask CSR: op/fixed kit & burs, SSIHS, crown remover .bur/kit, dam kit, bite block, bite fork, ET burs, dicomp DISP: anesthetic, porc shade guide, light tip, Vitrebond, Reprosil, Ultratemp, glass slab IMPRESSIONS: 2 guns, lots of tray adhesive, light body, medium body, Regisil, nitrile gloves? POST: GPX, parapost kit, RelyX AMALGAM: gluma, automatic condenser COMPOSITE: shade guide, comp kit/gun, comp/flowable, fmishing strips, diamond points/paste ION: Jet kit, rubber mixing cup INTEGRITY: integrity kit, more Reprosil TEAM CART: Scope, LA tip, green/red wax, Ion crown, rubber cup/pumice, CHX? IMPRESSION: cordlHemodent, Astringodent, gun tips/little tips, adhesive brush, BUILD UP: matrix band, rubber dam, ethanol MY CART: custom tray/casts, scalpel, mixing pad, Moore discs, pineapple bur, articulating paper (temp) THE USUAL: topical, floss, curing light BUILD UP: wedges, etch, bond, articulating paper GENERAL: BP cuff, safety glasses, mirror; gloves, loupes; cup holder LOCKER: facebow

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[PROCEDURE] Sign in: pt consent, BP cuff/stethoscope, pt goggles Take shade: shade guide Check occlusion: how anterior look in MIP, which teeth grab shimstock, canine/group function Try in custom tray, paint tray: tray adhesive, brush Anesthesia: topical, Q-tip, LA, tip, syringe Cut off old crown: high speed, crown remover bur, crown remover stick Remove caries & old filling & calculus & cement: slow speed, operative burs, scaler, rubber cup, pumice Isolate tooth (so bacteria don't get between the tooth and filling): rubber dam kit, rubber dam, floss, matrix Clean tooth with CLX or ethanol or something Prep and place post: GPX, parapost kit, RelyX Liner: DycaVLife, mixing pad, spatula Base: Vitrebond, mixing pad, spatula, curing light, light tip Amalgam: matrix band, wedges, amalgam, operative kit, wet cotton, automatic condenser Composite: composite, operative kit, ethanol gauze, curing light, light tip, finishing burs/points/strips/discs Reduction matrix: reprosil, scalpel Prep: occlusal reduction, convergence, no undercuts, good margin Prep: high speed, slow speed, fixed burs, operative burs, cotton rolls, parotid shields, green wax, red wax Pack cord: little cord, big cord, hemostat, cord packer, tweezers, scissors, Hemodent/Astringodent/LA Ion temporary: ion crown, scissors, jet, rubber mixing cup, big spoon, Moore sandpaper disc, finishing burs Integrity temporary: reprosil, integrity kit, Moore sandpaper disc Remove cord Impression: custom tray, tray adhesivelbrush, guns/tips/tiny tips/COE syringe, light/medium/heavy body Bite registration: gunltip, regisil Facebow: facebow, bite fork, tray adhesivelbrush, regisil, gun/tip Cement temporary: UtIra Temp Adjust occlusion: articulating paper, finishing burs


OPERATIVE APPT [SETUP] CUBE: CMS login, items in tx plan, approved, pull up x-rays TEAM: PPE, cart TEAM: blue napkins, head covers & tape, wrap TEAM: cotton, suction tips, mask, CUP FOR WASTE AMALGAM CSR: operative kit/burs, slow/high speed, rubber dam; dicomp points, bite block DISP: anesthetic, light tip, pallident, gloves AMALGAM: gluma, automatic condenser COMPOSITE: shade guide, comp kit, gun, comp, fmishing strips, diamond points TEAM: Scope, LA tip, matrix band, rubber dam, ethanol MY CART: topical, floss, curing light BUll.D UP: wedges, etch, bond, articulating paper GENERAL: BP cufT, safety glasses, mirror; gloves, loupes; cup holder SETUP: Handpieces, 3-way, burs, suction tips; syringe, topical, punch dam, ligate clamp, matrix band

[PREP]

Sign in: pt consent, BP cufii'stethoscope, pt goggles

Topical, place LA, take shade

Check occlusion so you know what it's like right now

Choose tooth to clamp, choose clamp, ligate clamp, punch dam

Place rubber dam, slow suction in mouth

Maybe pre-wedge

Ideal prep, remove caries

[MATRIX BAND]

Setup matrix, place matrix band

Wedge, check gingival seal

Loosen band slightly, burnish for contact, check contact, recheck gingival seal

[AMALGAM]

Get someone to mix amalgam for you

Either etch/primelbond or use gluma

Condense, burnish, carve

Remove wedges/matrix

Carve IP and gingival margins, carve anatomy

Check/adjust occlusion

[COMPOSITE]

Etch/primelbond

Place composite/shape/cure in layers

Finshing strips, soflex discs, 12 fluted burs, dicomp points, diamond paste

Check/adjust occlusion

[CLEANUP]

Cut away rubber dam, rinse pt well


ORAL SURGERY APPT

[DOWNSTAIRS] Where are you sheet, backpack in locker PPE, safety glasses, pen, palm pilot, memory stick, BP cuff Honors oral surgery: Monday morning, Wednesday morning & afternoon, Thursday afternoon

[UPSTAIRS] Name on list Get cubicle, log in Wrap, tape, head covers, bib, mask, gloves, instrument card, tooth marker Donut talk

[PROCEDURE] Get label, pull up chart, read chart, look at x-rays Fill out card: I) Age, race, sex 2) Health 3) Allergies 4) Medications 5) Circle: extraction, bite block, forceps 6) Tooth #, blood bourn disease, name, date Get patient I) Take vitals, vitals on card 2) Review health history with patient 3) Sign consents 4) Look in mouth, mark tooth, double check instrument choice 5) Type vitals in computer, click boxes Teacher signs card (bring pen), get instruments (bring tray) Setup instruments: water, anesthetic, bib, suction Teacher comes: l) sign in, 2) change doctor, 3) check x-ray and tooth Topical, anesthetic, test anesthesia Extract tooth Look in socket: broken root tips, granulation tissue, sinus communications Sinus precautions(?): antibiotic, anti-histamine, nasal spray, pain pill, Loratidine, Afrin Look for infection: socket, cheek, vestibule, x-ray Suture if needed Bite on gauze Anesthesia notes, treatment notes, address complications/infections in additional comments Prescription in computer Teacher comes: looks at socket, approves prescription, reads tx notes, signs out, signs prescriptions Take bib and suction of off patient Give pt prescriptions & post-op instructions Dismiss patient Clean up


PEDO EXAM & PROPHY APPT [SETUP] CSR: BOE, prophy kit, slow speed DISP: HOME CARE KIT, floss for me, fluoride tx (get fluoride for children under 6) TEAM: PPE, cart PEDO: blue napkins, head covers, wrap; cotton, suction tips, mask CUBE: handpiece & 3-way, maybe take off head rest TEAM CART: Scope, disclosing agent, prophy paste, prophyangle MY CART: gloves; floss, cup holder; kid's glasses, mirror; loupes

[PROCEDURE] Get height/weight Screening note, assign, activate, add tx, approve tx Sign in, approve tx Health history, medications, sign off on both Disclose, prophy w/rubber cup, scale if needed, maybe floss, maybe fluoride (maybe later) Oral exam (soft tissue exam) Find out which teeth are there, permanent vs primary, is tooth loose (easier to write on paper) Chart existing restorations, caries, and plan for each tooth, teacher checks Figure out what x-rays are needed, add to tx plan, order x-rays, take x-rays Enter chart into the computer, get perio case type, caries risk, Frankel behavior, teacher checks, signout Do fluoride as last thing Patient accounts (Medicaid), cashier


PERIO REEVAL APPT How long does it take for gingivitis to heal? 10 days-2 weeks How long does it take for periodontitis to heal? 4 weeks-6 weeks What do we want to happen in that time? Shrinkage of puffy tissue, reattachment oftissue How do we evaluate this? Color, contour, consistency; probing depth, recession, mobility, furcations (usually don't go away), gingival inflammation, plaque, mucogingival defects Where does probe stop in health, gingivitis, periodontitis? Coronal JE, where JE meets CT (gingival fibers), into CT. Collect data Analyze data. Is pt healthy? Healthy pt: Deplaque (at a minimum), put them on maintenance Unhealthy pt a. Signs ofnot healthy: deep pockets, bleeding, inflammation b. Try to figure out why pt isn't healthy. What's causing the disease? OH, immune system, diabetes, overhang, we didn't remove plaque and calculus c. How do you treat it? i. MoreOH ii. Retreat iii. Arrestin or local medicine iv. Compromised maintenance v. Refer How long should it be between maintenance? Chart maturity and mass of subgingival plaque vs time. Draw a line ofthreshold for resumption of disease process. On the average, it reaches threshold at 3 months. There is scientific evidence for 3 months. There is scientific evidence for every 6 months. Start everyone out on 3 months. If they're doing good, bump them up to 4, NOT to 6. Ifthey're doing bad, bump them down to 2 or retreat or something. If they're OK at 3, keep them at 3. 1) 2) 3) 4)

Say infection, not inflammation or disease.

[SETUP] CSR: prophy kit, slow speed, cavitron inserts DISP: HOME CARE KIT, prophy jet, anesthetic, floss/super floss/floss threader TEAM: PPE, cart CUBE: CMS login, items in tx plan *OID*, approved, pull up x-rays, untangle hoses, dust signature pad TEAM: blue napkins, head covers & tape, wrap (light & switch, keyboard, buttons & handle) TEAM: gauze/cotton rolls/applicators, suction tips, mask CUBE: handpieces & 3-way, napkin chain, anesthetic TEAM CART: Scope, disclosing agent, prophy paste, prophy angle, LA tip MY CART: gloves; topical, floss, cup holder; safety glasses, mirror, BP cuff, cavitron; loupes

[PROPHY] Take BP/premed/blood sugar Sign in, check/modify/approve tx plan Disclose pt, record plaque (CARIES RISK, PERIO CASE), OHI (show pt plaque & how to brush) Remove calculus & sub-G plaque with cavitron & hand instruments Floss teeth Check calculus & sub-G plaque removal with explorer & gauze/air syringe/mirror Polish teeth with rubber cup & prophy jet, remove coronal plaque Floss to get prophy paste off Disclose again to see if you've missed anything (optional)


PULPOTOMY & CHROME STEEL CROWN APPT Check for pedo chair availability when you make the appointment.

Reserve the nitrous tank at the dispensary as soon as you make the appointment.

[GENERAL SETUP]

CSR: KIT: pulp/op/CSC, BURS: op/CSC/fixed, slow/high speed, rubber dam., bite block

DISP: anesthetic, nitrous tank & tube & mask, formocresol, sterile water, sterile cotton, glass slab

TEAM: PPE, cart

CUBE: CMS login, ORDER NITROUS, items in tx plan, approved, pull up x-rays, untangle hoses

PEDO: blue napkins, head covers & tape, wrap (light & switch, keyboard, buttons & handle)

PEDO: gauze/cotton rolls/parotid shields/applicators, suction tips, nitrous suction tip, mask

CUBE: handpieces & 3-way, napkin chain, anesthetic, rubber dam

PEDO CART: Scope, LA tip

MY CART: gloves; topical, floss, articulating paper, cup holder, IRM, mixing pad; safety glasses; loupes

[PROCEDURE]

Pt height & weight, calculate max anesthetic dose (18 Ibs = 1,36 Ibs = 2,54 Ibs = 3, 72 Ibs = 4)

Nitrous Place LA Place bite block & rubber dam PULPOTOMY Remove caries Remove unhealthy pulp Apply cotton pellet under pressure to stop bleeding (how long?) Apply formocresol pellet for 3-5 minutes, pulp should look brown Mix IRM, wad up IRM, place IRM, smooth with wet pellet, rinse mouth CROME STEEL CROWN Prep mesial and distal, get clearance with an explorer (break contact), round line angles Occlusal reduction (1-2 rom) Remove rubber dam Choose a crown based on quadrant, which tooth, and MD width Look at occlusion on the same side and the other side 2x2 in back of throat, try on crown to check MD width, choose a different crown as needed Check fit: teeth touch on the other side, teeth touch on same side, gum blanching Adjust crown with scissors???, polishing point???, and crimper, try it on again Mix Ketec-Cem, cement crown using bite stick 5 minutes 100% oxygen AFTERAPPT Pt pays

Print demographics and tx plan and get pedo points [CLEANUP] Sharps Count and return CSR & dispensary items Discard trash Disinfect one counter, disinfect my stuff, put it away Disinfect cubicle


Faculty check, sign out Fluoride tray

[PERIO MAINTENANCE] Take BP/premed/blood sugar Sign in, check/modify/approve tx plan *Probing (see ifpt is improving/going down hill) Disclose pt, record plaque (CARIES RISK, PERIO CASE), am (show pt plaque "& how to brush) Remove calculus & sub-G plaque with cavitron & hand instruments Floss teeth Check calculus & sub-G plaque removal with explorer & gauze/air syringe/mirror Polish teeth with rubber cup & prophy jet, remove coronal plaque Floss to get prophy paste off Disclose again to see if you've missed anything (optional) Faculty check, sign out Fluoride tray

[SCIRP] Take BP/premedlblood sugar Sign in, check/modify/approve tx plan Disclose pt, record plaque (CARIES RISK, PERIO CASE), ORr (show pt plaque & how to brush) *Explain perio disease *Topical, place anesthetic Remove coronal calculus, check with gauze/air syringe/mirror, coapt tissue Remove sub-G calculus and plaque, check with explorer, coapt tissue, remove granulation tissue Deplaque previously SC/RP areas Floss Polish Faculty check/sign out


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