tips and tricks

When treating sleep in a dental setting, it is useful to have a basic understanding of sleep and sleep staging to be able to interpret the results of a sleep study correctly and to be able to communicate effectively with medical colleagues. From Sleep Medicine 6th edition What is sleep Sleep is a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment. It is also true that sleep is a complex amalgam of physiologic and behavioral processes. Sleep is often associated with behavioural traits such as supine position, quiescence, closed eyes. Parasomnias can occur including sleep walking, sleep talking and tooth grinding. What are the stages of sleep? Two very separate stages of sleep have been identified: REM and Non REM sleep. NREM sleep is separated into 4 substages as defined by the EEG measurement axis (brain waves). NREM EEG is described as synchronous and have characteristics such as sleep spindles, K complexes, and high voltage sl...

I've applied for subscription to the Royal Australiasian college of dental surgeons. This is the first step towards taking the Primary examinations which is a test of Anatomy, Histology, Physiology, Cell Biology & Biochemistry, Pathology and Microbiology. It is a qualification that displays one's dedication to learning in the field of dentistry and is a prerequisite for many post graduate courses such as those in universities for specialisation and the grad dip conscious sedation that allows you to perform IV sedation in general practice. I am still deciding whether or not to take the exams this year as they are quite full on. My thoughts are: -This is a test of my dedication and willingness to learn. If I can't follow through with the primary exams then I am unlikely to be able to follow through in specialising. -It is better to do this now as I haven't settled down to a long term job yet. -It is better to do this early while I'm not too far away from my u...

Caries that has just progressed past the DEJ can be a challenge to treat. The milder extent of the cavity preparation can be more difficult to manage than large preparations due to the smaller access and higher risk of voids and maladaptation. After preparation, the cavity prep can often appear like in Figure 1. Class 2 cavity preparation. In shallow caries just into dentine the preparation may be similar to the blue shape. Removal of the orange section may improve visibility and access This small prep although conservative and in the patient's best interest it may cause a sub standard restoration to be placed. The small access affects placement of etch, prime and bond as well as the placement of restorative material and access for finishing and polishing. During preparation, the contact may not be broken which will make the placement of a matrix band difficult. You can get around this by using a stiffer band like a Tofflemire and forcing it through the contact or by widen...

Recently I performed a splinting procedure for mobile lower incisors in a perio patient. She presented with significant calculus buildup and radiography showed severe bone loss. Therefore I knew that once I removed the calculus which was bridging the teeth together there would be at least grade 2 mobility. Everstick perio was the product I used. This is because I wasn't prosthodontically adding a tooth onto the bridge and everstik perio has half the amount of fibres as everstick C&B (2000 as compared to 4000) therefore would be thinner and more comfortable. I knew that once I cleaned the calculus off the teeth would be hard to handle as they would be mobile. If done under rubber dam I would not be able to check the occlusion until the teeth were bonded and the dam was off. This may be disasterous as the bridge will be hard to remove if the occlusion is wrong. What I did was ensure the occlusion was comfortable at rest (sometimes it may not be due to traumatic occlusion) The...

Notes taken from the ADA webinar: Basics of clinical photography by Dr. Peter Sheridan Clinical photographs are used for records and documentation but also professional communication, education marketing etc Issues with intraoral cameras are they have a limited range of views. It is easy to use but poor quality, colour and distortion. Can't integrate the image into the whole mouth context or comparison with other teeth Criteria when choosing cameras -Quality of images -Lightweight -Value -Integrated (can buy all hardware from the same manufacturer) -Ease of use -Depth of field -Special features: eg in built post production software -Longevity Lens should be 60mm not 105mm macro lens. These days, DSLRs are using apsc or dx sensors which are smaller which changes the field of view of the lens. The 60mm lens working at 1.5 crop factor and acts as a 90mm lens and the 105mm lens works as a 150mm lens. The 105mm lens will be heavier, have no depth of field, and will go hu...

A few thoughts about the technique behind mental nerve blocks: - The path of the IDN through the mandible starts at the mandibular foramen. This is the ideal site for the deposition of anaesthetic for an IDB. as the nerve approaches from superiorly and posteriorly a higher chance of success is gained from injection most posterior and superior. However, too posterior may result in affecting the facial nerve which lies just posterior to the ramus of the mandible. Too far anteriorly will stop the spread on anaesthesia due to a ligamentous attachment to the lingula (sphenomandibular ligament) - Upon entering the mandible, the IDB tracks anterior through the bones near the apices of the lower teeth. At the molar region (if I recall correctly), it sits more to the lingual cortical plate and it shifts to a more buccal position at around the premolar region. This and the denser quality of the bone is why infiltrations have a poorer success rate on lower posterior teeth. At the site of the me...

The following is a case report of a procedure where in hindsight I would do things a little differently This patient is a 50 Year old female who presented with the occasional pain to bite down on a lower left tooth. Immediately when I hear this I have an idea in my head as to the possible causes. Firstly the location seems to be fairly reproducible and it only appears to happen when she bites on a certain tooth. This almost completely rules out myofascial pain which would be more constant and deep and would be sore if she bit on any tooth on the affected side. Palpation of the masseter and lateral pterygoid will assist in ruling this out. Do be careful as there is often a secondary myofascial pain from the toothache or from bruxers who often have cracked teeth as a finding. Acute periapical pathology is an option but this would often lead to extended pain after biting and clinical examination should reveal tenderness to percussion which is reproducible. Pulp testing assists in determ...

Molar extractions are complex things there's no doubt about it. What makes them so complex is their variation in anatomy ranging from root shape and length as well as curvature, number of roots and the increased surface area of PDL. The surrounding structures add their own complexity with variations in the density of cortical bone as well as surrounding structures of the maxillary sinus and IDN. Therefore it is prudent to plan out extractions properly and have a good idea of how the surgery will go. Here are a few tips I've picked up on surgical planning: -Mandibular posterior cortical bone is dense, don't expect much expansion of the socket -Don't be afraid to raise a flap or go surgical or sectional if it will be easier. Destruction of bone is less of an issue if they aren't planning for an implant. However in the posterior region where extractions are generally more difficult, the volume of bone and soft tissue is less of an issue. Once you remove the first ...

NB: This is definitely not my idea We make putty stents for the palatal buildup of wear and trauma cases so why not do this for caries cases as well? Patients who present with large carious lesions that have the palatal shell intact or very near anatomical contour can have a putty stent made intraorally. If there are any defects or missing bits of tooth structure these can be mocked up in composite or even sealed with flowable or wax and an intraoral putty impression can be taken and trimmed. After the prep you have a putty stent that replicates the ideal palatal anatomy without a waxup! The same goes for wear cases etc. If the mockup is done intraorally with composite then the patient can appreciate the shade, shape and occlusion to approve before final adhesion. Once you have gotten everything perfect, you can take a putty stent of this mockup. This saves on lab time and costs but the human jaw is the most accurate articulator you can find and it may save of time with occlusal adju...

I'll start by putting forward a question to you: "Would you rather be missing your little toe or your front tooth?" Dental health is more important to your patients than we or they realise. Not just from a biological point of view but also a psychosocial, mental health and general health point of view. Loss of teeth ultimately leads to poorer function, aesthetics and declining self image. In this world of consumerism we find aesthetics becoming more of a priority and something that is traded upon like any commodity ranging from vouchers for veneers to bargain discounts on implants. I don't blame patients for being confused and sucked in by some of these gimmicks. I also do see where they are coming from when they neglect their oral health. However, it did initially confuse to me as a health professional and someone who has never had a significant oral or general health issue. Patients always seem to have the same excuses... -I've always had bad teeth -It...

In a working environment that puts high importance on personal protection equipment, we often forget about the protection that our ears need. High speed suction and handpieces can produce sounds over 85dB and up to 100dB which is within the range to produce damage to the delicate auditory sensory organs. This damage is preventable but irreversible. Therefore it is prudent that we tackle this problem early on in one's career very similar to poor posture. I use earplugs from the brand Earasers but you can see an audiologist to make custom in ear plugs that will dampen but not completely remove the noise of the dental operatory. I find that with these ear plugs my ears don't ring at the end of the day as they would without them however without regular hearing tests I would not know if this is making a noticeable difference. Signs of damaged hearing include tinnitus, sound distortion, difficulty interpreting complex sounds especially higher tones and the enunciation of S, Z and...

Don't ever forget that Root surface caries is a bitch to treat . The individual chemical makeup of dentine makes it uniquely predisposed to catastrophic caries. -The more apically you look, they thinner the dentine is before it reaches the pulp. It also means that any loss of tooth structure due to prep will result in a larger percentage loss of cross sectional area. Therefore the same amount of tooth structure lost on the root will result in a higher risk of catastrophic fracture -This is a site patients often neglect to clean. the reason the recession appeared in the first place was likely influenced by poor oral hygiene, once the dentine is exposed the bacteria can get to work dislodging the mineral in the exposed root surfaces. root concavities suck as between molar and premolar roots are exquisitely hard for patients to clean without the proper instruction -Dentine has a critical pH of 6.5 as opposed to 5.5 for enamel so any caries on dentine will be faster progressing a...

This is a message for those dental students entering the big wide world. Take it easy. There is no rush to be the biggest and the best. On a daily basis we are exposed to flash and fancy dentistry but you have to realise that this isn't what most people do day in and day out. Menial tasks such as checks and cleans and simple restorative are the bulk of most if not all general dental practices. Get good at the simple stuff first . Focus on your bread and butter dentistry in getting efficient, high quality dentistry going and focus on the fancy stuff later. What is more important and impressive than doing high quality fine tuned prosthodontic work is to give painless injections, managing patient expectations and providing a comfortable and stress free appointment. In the end, no matter how fancy your work is, the patient has to like you to return and give you repeat business. It is all well and good to have high aspirations, but don't rush into things at 100km/h. And never think ...

Thee places that patients have the most difficulty with handling intraoral films are any lower films due to lack of space and proximity to the sensitive tissue of the floor of mouth and upper posteriors due to gagging. I believe I've already made a post about managing gagging with impressions and intraoral films so this will focus of xrays of the lower teeth. The most common film including the lower teeth is the bitewing. This is an excellent tool to screen for interproximal caries, subgingival calculus and bone loss. Compared to a lower PA radiograph it is fairly well tolerated. Situations where it is not tolerated are gaggers, obese (who have significant increase in tongue size), and nervous patients who have increased muscle tone during procedures and are less likely to follow your instructions. There are 2 options of films each with their own pros and cons: -Thin PSP or analogue films: These tend to have sharper edges and have more issues in the feeling of cutting the fl...

Today I had an interesting presentation of a lower 8. It had almost fully erupted but still had a distal operculum that had caused an initial bout of pericoronitis. It was obvious that there was proper spacing for the tooth to fit in the arch and My question is if the operculum would receede naturally or would require removal. The patient was 25 years old and apaprently it had been a while since the eruption of the tooth. A couple of thoughts: -Start with conservative management, improve OH, and mouth rinses -Antibiotics are not indicated for mild pericoronitis. -Do not perform an operculectomy on an inflamed site, it will bleed more, be more difficult to handle and once inflammation has settled, the result may not look ideal as this site will be larger than at its baseline state. I will recheck this case and check the healing.

No one can deny that dentistry is a stressful profession. It is not the most physically challenging though it does have its physical hurdles but I do believe that the mental side of the job takes the biggest toll on its workers. I have heard many explanations of the high suicide rate for dentists including the fact that there are just less dentists so any suicide will obviously make a bigger statistical difference. Here are some of my thoughts on the matter than I personally have experienced or have noted in others on a day to day basis: -Dentistry attracts a certain personality: Perfectionist, anal retentive, uptight individuals. The academic marks required to get in are fairly high and university places are competitive so the applicants it attracts have generally always aimed high and wanted the best performance out of themselves. When it comes to their work, this can leave them feeling unfullfilled and unsatisfied at the outcomes of their treatment. We forget that half the work is...

So it was mentioned to me that multiple layers of fibres can be used in the pontics of fibre bridges. A common situation is the replacement of lower incisors lost due to perio. Then you get the benefit of splinting as well as tooth replacement. With the first palatal fibre cured into place joining the abutment teeth together why not tack another strip of fibre labial to this in the pontic space. This is only possible when you don't have the natural tooth to adhere and are recreating the teeth in composite resin. The more fibre in the bridge the stiffer and potentially stronger it will be. After this second layer, a vertical fibre for each pontic tooth can be used as well as a horizontal fibre labial to that. This is the densenst arrangement with fibres going in different directions which will provide a satisfactory result. the translucency of the fibres means that not much composite is required over them to provide a good aesthetic result.

Often there is the temptation to take on more and more responsibilities. This is especially common in people who have difficulties saying no and who don't want to disappoint others. What you do have to remember is that you yourself must always come first. Though this may seem selfish, no one will care for you in the end other than yourself. Approach commitments with a rational mind and ask yourself if it is too much for your schedule. Do take into account that it is important for mental health to have time for leisure and recreation even if that is just lying back and doing nothing. Taking on tasks, committees and commitments may be beneficial to others but it may not be for yourself. Don't be afraid of saying no

Okay I think it's about time I start making a series of posts on dental sleep medicine. I have been doing Derek Mahony's mini residency for almost a year now and have learned a lot. What this series will cover: -Pathophysiology of OSA, snoring ,TMD and bruxism -The link between Bruxism, TMD and OSA -Parasomnias -Clinical examination -Sleep studies -Management strategies -Side effects of treatment and their management

Today I was in a situation where there was a 46 tooth with an MODB fracture. The mesial and distal margins were equigingval. The tooth is set for an endo or and exo but I did not have the required equipment to perform either (In the dental truck). So the plan is a temporary restoration and the patient will seek treatment privately. There are two options from here. -Restore to decent contour and contact -Restore with a stump with open contacts Ideally I would have a good contact to stop food packing but at a copmromise I would consider a wide open contact to allow interdental brushes to fit in. Without anaesthesia which was my plan, Wedges would be painful and making a contact would be difficult. This was due to the equigingival margin. In the past to make a decent contact I have used a light cure GIC like Fuji2LC and restored in stages. Sectional matricies are usually too unstable to be used due to the minimal surface area they are in contact with the tooth and there is the same ...

In the past I have had difficulties in placing the clear mylar strips in class 3 cavities where there is a strong or a sharp contact as in the picture below. -Tight contacts tend to bunch up the matrix and when you eventually jam it down it has a poor contour -Sharp contact will do the same, where there is a thin bit or supported incisal edge and it will catch or dent the matrix -Sharp incisal corner i.e if there is a small chip just off the location of the incisal corner. This may be in composite veneer cases where you want a clear strip to separate the teeth or in class 3 cases in a bruxer. I have found the matrix may want to go into this little divot rather than sliding between the teeth Solutions are currently: -Take a bur or polishing disc and cut off the obstruction. This is destructive especially for the tight contact case where there is a fair bit of supporting tooth structure -Use a tofflemire matrix or other metal matrix. This is more rigid and can be forced between th...

One issue with material handling I have had in the past is with GIC. Something about the texture and the fact that it self sets makes it incredibly difficult to handle in my hands. Occlusal cavities aren't too bad as you just bog it up making sure to avoid incorporating air bubbles and then trim down the rest but in the aesthetic zone I do find it difficult to place and polish to an acceptable result. Some strategies I've used in the past: -Bond on a microbrush or instrument to improve handling -Bog up and trim back: Tended to have a poor result with bur marks in the GIC -Cover with bond and cure for a good finish: Apparently G coat plus is used for this which I haven't had experience with yet Currently my strategy during class V GIC placement is to overfill the cavity just very slightly (practice makes perfect) then to use a flat plastic or a carver to pat the material down and adapt the margins. I find patting works better than spreading as he material tends to pu...

Hi, just some tips for placing rubber dam that come to mind. Not sure if this is a repeat from the past. Rubber dam is the best and most reliable way to isolate teeth. I do believe that it will improve outcomes of any treatment it is used in. It is essential in endodontics. Imagine a sharp endo probe or caustic sodium hypochlorite going down the patient's throat. Ouch. -I have been using No 7 Hygienic clamps for molars, 2A clamps for premolars, anterior clamps for anteriors. This seems to fit most purposes. -Do be cautious of clamps on heavily broken down or root filled teeth.  There is a lot of force from those prongs -When you are applying topical to the injection site, place some on the gingiva around where the clamp will go. it will make it much easier to tolerate the clamp -You can apply the remaining topical to the underside of the dam in the interproximal area as a lubricant to slide down between the contacts -This video pretty much shows how I use floss ligatures htt...

Okay so completely forgot I had this blog going but did notice some notifications that people are viewing it and even commenting. Although I am highly suspicious that these are bots it is a good reminder for me to keep posting as my dental journey after all is an ongoing one. One treatment modality I have been able to use a few times is that of fibre reinforced composites. As far as I can recall there are many different fibres that can be utilised but the everstick bran I have used consists of glass fibres presoaked in unfilled resin for bonding. I have used non soaked fibres in the past but they are far more cumbersome to use with extra steps. I find it useful to imagine that the fibres will act as stress breakers and will strengthen the overall composite likely similar to metal scaffolding in concrete. They are useful even in normal composite resin restorations as I can imagine that placing a net of fibres between increments will strenghten the restoration. There are composites a...