tips and tricks

I will use the example that I encountered recently: a class 2 div 2 case with caries between the central and lateral but this is relevant to caries in any crowded area. Caries tends to be more severe in these areas due to the inaccessibility of cleaning and the culturing of anaerobic environments. Overlap of teeth hinder effective access of toothbrushing and allows a protected environment from the cleansing effect of food movement and saliva. Tight contacts hinder the passing through of floss and calculus buildup further prevents this.  Caries tends to initiate under the contact point and due to their root torque, class 2 div 2 teeth tends to have a long contact point more apical to the ideal position. Therefore caries tends to be positioned closer to the DEJ and more severe in size. Also, upon caries removal, the distance between the cervical restorative margin will be minimal to none. Once I had caries freed this case, the contact point had not been present because the teeth w...

Bitewings are a narrow view into a wider area. Generally, a size 2 film which the majority of dentists will use will show 4-5 teeth in view. This will usually miss the 8s, distal of the 7s and distal of the 3s depending on the anterior posterior positioning of your film. The posterior lateral surface of the tongue will tend to push the film superiorly and anteriorly and the curvature of the mandible will stop the film moving too far forwards. Caries will only present on bitewings when a significant portion of the buccolingual width is involved. Therefore as it is well known, they are useful for diagnosing interproximal caries where the buccolingual width is narrow near the contact point. However, a few things can confuse the interpreter of the radiograph: Occlusal caries is unlikely to show up on a bite wing until large. If you see a radiolucency at the base of a fissure, it is very likely to be carious. Buccal and palatal pit caries show up better as they penetrate into the tooth...

The more time I spend in clinical practice, the more I appreciate the idea that the more information we get off the patient, the better our treatment outcomes. As I begin to ask more questions, I begin to wonder how much I have been missing in the past. I am learning that dentistry alone can't win against an inhospitable oral environment. I spent a good hour with a patient today just digging through their history and trying to uncover the puzzle of his dental disease. I think a good rule is, "Nothing happens for no reason" or to put it another way "If the story isn't adding up then you're probably missing something." I think at university, we were given the tools to uncover these details but weren't taught how to use them. I also think that if you can agree that it is of utmost importance to modify the oral environment prior, during and after treatment, you can agree that we all need to dig a little deeper as to what the patient is doing to themsel...

So I had a brief encounter with a salesman in Harvey Norman today and a few thoughts occurred to me. This is how it went... I was browsing around the laptop and phone section, wasn't looking for anything in particular, just trying to pass the time. I'm dressed as scruffily as possible, t-shirt, shorts and thongs. Try to get past the appearance of a patient. IT MEANS NOTHING. as most people go I do fairly well for myself but I do not dress like it. When someone says they can't afford dentistry it doesn't mean they have no money, it simply means they do not see enough benefit in spending the money they have on what you are offering. When a patient requires comprehensive treatment planning we have a duty to inform them of options we assume is past their means. The right patient with the right motivation will spend much more than you will expect if they think you and your skills are worth the money. A salesman comes and asks if there's anything I need. He smells.....

Haven't had much time to post anything new on this blog but I'm starting to get back in the swing of it, to answer some comments and write some more posts. Have a few interesting topics that I want to write about. It's been a fairly up and down year for me with a lot going on in work and personal life. My colleagues are going through the primary exams right now and I wish them all the best. Unfortunately I dropped the commitment earlier in the year due to some reasons previously discussed. I'm also moving back to Sydney in the next few days smack bang in the middle of the exam schedule. After working rural for so long the big smoke scares me but it will be good to be closer to family especially with the health scares we've had in the past year or so. If anyone is following this blog I hope all is going well on your end. Things change and people change and someone who is great one day can be struggling the next. Just remember, help is always there to those who as...

The temperature of any material hastens its setting and breakdown. Composite resin has the desirable property of being command set with our curing lights so the temperature variations with composite resin are mainly to affect its handling properties. Too cold: Composite that is too cold will be thicker and more crumbly. Arguably this is beneficial to allow you to pack composite against a matrix band to generate a tighter contact that will stay in place while you cure. However the fact that it comes out of the capsules and tubes crumbly ensures that it will be impossible for you to avoid incorporating a void in your restoration. The most crumbly part tends to be right at the nozzle which is also the part exposed to air and likely to dry out over time. This will likely be the part that is placed at the very base of your restoration hence the most important to getting a good seal at the tooth interface. You will find it is very difficult to squeeze cold composite out of a compule so gen...

Wear facets between upper and lower teeth can be a telltale sign of how a patient functions. A few points. Wear facets on cuspal inclines can indicate posterior function in a non axial direction.  Linear wear facets (i.e elongated, not a single spot)  can indicate a slide from first contact in CR to MIP. Large wear facets only indicate wide broad contacts not heavy contacts Worn canines can indicate nocturnal bruxism. Be sure to get the patient to manipulate their jaw to match the wear facets up. Patient who contact in extreme laterotrusion almost inevitably sleep brux. This makes a lot of sens to the if you point it out and it can be a good point to convince them to seek more diagnostics Patients who still have mammelons are unlikely to brux on anterior teeth so either they are trapped in MIP and exhibit more of a clenching habit or the have an anterior open bite relationship.

Again I find the need to remind myself that we are the health professionals and we are responsible for our actions so we should never let anyone else dictate what we do. Don't let the eye rolling of your dental assistant or the begging of the patient force you into a situation that you are uncomfortable with. Of course you should be working for the improvement of health of the people you encounter but not at the risk of your professional ethics or personal values. An example: A patient comes in with a toothache begging you to do something. You take a PA and lo and behold it is a carious lower 8 with divergent roots sitting right next to the IAN. Your options are to send for an opg for a better view of the situation and attempt the extraction yourself or refer off to someone more experienced. In this case I was not confident with the extraction but was won over by the patient's need and the fact that there was a large PA lesion around the mesial roots which (despite logic), I ...

A little while ago I posted on detecting and managing curved roots in premolars. http://dental-tidbits.blogspot.com/2019/06/premolar-extractions.html I recently extracted an upper molar with fairly curved buccal roots. One thing I noticed was the xray exposure happened to obscure the curvature of these roots. One tip I would suggest is to spend adequate time inspecting your preoperative xrays before starting the extraction. This can be before the appointment if the procedure is planned or during waiting for local anaesthesia  to settle in if it is not. Play with the contrast and brightness and sharpness filters if your program has one. Thicker or thinner bone can obscure root features and thin roots can be burnt out by higher exposures. Slowly follow or trace the external boundaries of the root surface to describe the root shape and never underestimate the variability of posterior root forms. The good thing about upper molar roots is that the form is usually quite defined o...

There are many courses set out to improve the way we communicate and speak to patients in an effort to improve rapport, heighten treatment acceptance and deal with anxiety. However these teach you the skills to use your mouth and body to get a message across to others. There doesn't seem to be enough emphasis on "listening skills". I've seen it in my reading, day to day life and practice that listening is the most important skill we can have as a health professional. This is because diagnosis is the first "medical thing" we do and we can't get a good diagnosis without good rapport and we can't get good rapport if we don't listen to the patient. Listening to the patient will almost always determine your treatment plan, affect patient motivations and improve rapport even without looking in their mouth. Too often health professionals have the habit of cutting patients off early and asking closed ended questions that require short sharp answers. e....

I attended Mike's course in Sydney at the end of August and found it a decent set of lectures. Nothing ground breaking as I have explored a little bit into occlusion in the past but it definitely served  to clear up a few misconceptions I had and consolidate a few concepts I was unsure about. There will be recordings available through restoring excellence so I will probably purchase this when it becomes available and make a few posts on occlusion. The good thing about Mike's lectures and philosophies is that it combines multiple points of views from different occlusal schools into a predictable and workable treatment flow. Topics I will be blogging about are things like: splints: designs and uses: ideal occlusal contacts, how to check lab work before it is inserted, concepts of CR, the uses of leaf gauges, how to manage cases taking into account structure, engineering and aesthetics etc.

Just a spot where you can get caught out when clearing dentine removal. Make sure you have removed all enamel overlying the carious dentine and also have a clear DEJ before you switch to a slow speed for carious dentine removal. It is easy to get focussed once you have switched to the slow speed on the depth of the cavity while you risk failing to clear carious dentine at the DEJ. The other day I was preparing a wide, shallow class 1 carious lesions and in the name of "conservative dentistry" I failed to clear some enamel overlying the carious dentine. the slow speed round bur was clearing carious dentine well but there was one "island" of dark tooth that was not being cleared. It was easy enough to recognise by cleaning and drying the tooth and recognising that there was still some translucent material overlying the dentine. Switching back to a high speed diamond to clear this and clear the enamel margins to a clean DEJ allowed me to complete the preparation well...

Root canal systems calcify and dentine undergo scleroses in response to function, ageing and insults to the pulp such as repeated thermal or chemical insults (erosion, caries). As the dentinal tubules close, the ability for fluid movement to stimulate the pulp is reduced. Deposition of secondary and tertiary dentine increases the bulk of avascular tooth structure between the environment and the pulp tissue. This is beneficial for protecting the teeth against further insult but does raise difficulties during diagnosis of dental pain. When we are diagnosing pain we want to identify the odd tooth out e.g if there is a pulpitis we want to identify which tooth has an exaggerated response to stimulus compared to the surrounding teeth or if there is a pulp necrosis we want to see which tooth has no response compared to the surrounding teeth. Dentine sclerosis and pulp recession makes all responses less obvious and can complicate diagnosis. Technically the majority of tests we utilise for ...

Today as I stared at an extracted upper 8 covered in subgingival calculus, I mused on the difficulties of non surgical periodontal therapy. Removal of bioburden to the periodontal tissues is one of the long standing main aims of the treatment of periodontal disease. I don't dread treating perio but what puts me off is how difficult it is to do it well. I believe that if you are doing something you should do it right but perio is one of those tricky fields where things are stacked against you... Subgingival anatomy is hard. On the extracted tooth I held there was a multitude of anatomy unrecognised on simple 2D films. There was tight furcations between narrow roots, the interproximal root surfaces were concave and sloped upwards towards a very bulbous CEJ. I would imagine that I would spend quite a bit of time cleaning around this anatomy on the extracted tooth (and this is out of the mouth!) Of course the tightest spots are usually interproximal where the gingiva and neighbouri...

Natural undercuts on teeth are important for the retention of partial dentures, dental appliances and rubber dam clamps. It is undesirable interproximally next to denture saddle areas and when preparing a tooth for a crown or other indirect restoration. When assessing a patient for a partial denture or before rubber dam placement it is important to use your eyes to survey around the teeth to check for useful undercuts. Some molars have exceedingly straight buccal and lingual walls which makes retention of clasps and clamps difficult. Lingually tilted molars can make denture design difficult as it will result in a large open space under the lingual flange. You may want to design the denture so it sits anterior to teeth like this or fiddle with the path of insertion. Alternatively, mouth preparations can reduce these undesirable undercuts. With rubber dam placement, lack of undercuts may force you to use subgingival clamps or to clamp the soft tissue. You should be able to pick the t...

So I don't really know what I want to write in this post because my mind is scattered so it may be a bit of a ramble on. I'll try and organise my thoughts...I'll dump my thoughts on here and hopefully it sounds cohesive. You don't have to read this post. It's mainly for me to organise myself and figure out where I am heading. Motivation is one of those strange things that is there for you until it's not. Motivation to me is the inner drive that arises when you have a clear goal in your mind worth struggling for.  It's a fickle thing because every day there are distractions that may cause us to stray from the path that we have set for ourselves. There is no inherent malevolence in these distractions, they are what they are. Sometimes these distractions are negative because they cause us to stumble and fall. Sometimes they cause us to stumble and we respond by increasing our resolve to achieving our goal. Sometimes they can be positive and cause us to realis...

These are my thoughts and observations when facing a patient with occlusal issues. I am unsure if they have a scientific basis or actually make sense but it will be good to learn a bit more about occlusion at Michael Melker's course in Sydney in August. Taking notes of the size of a patient's muscles of mastication is important in determining the functional demands on their teeth. Like any muscle, continued use results in hypertrophy. It is less obvious in the temporalis as it is located over the temporal fossa that masks the true thickness of the muscle. The masseter is the main elevator muscle of the mandible and will be enlarged in patients who clench and brux.  Correlate masseter size with the patent's risk of sleep apnoea. I have found that the skinny, non class 2 patients with large masseters tend to be awake clenchers. Clenchers will show less wear on their anterior and posterior teeth as the force is mainly vertical though they may display chipped teeth and cra...

Today I had the opportunity to review a previous case: http://dental-tidbits.blogspot.com/2018/08/getting-good-contact-with-large-gics.html http://dental-tidbits.blogspot.com/2019/05/review-of-alternative-technique-for-gics.html The entire GIC debonded a couple of weeks ago about a 11 months after placement when the patient was biting on a mintie. It's not a bad result but still needs management. The idea of the initial GIC placement was as a temporary to monitor the pulp status and the tooth has been otherwise asymptomatic. One might question if it's asymptoamtic due to a receeded pulp or a necrotic pulp. The failure was adhesive with the entire GIC lost save for the vitrebond liner so this was placed back when I was doing more indirect pulp caps. As enough time had passed for pulp review I replaced the restoration in composite. I'm a lot less worried these days about causing pain with wedges. The patient consented to treatment without LA and understands there will ...

As my journey through the primary exams continues I have made some choices/realisations: -So far I have scrapped the idea of a second blog with content of the primary exams. It would be a fairly dry read and It will take up time I could be using for actually studying. -The timing of the orientation course is too late in the year. It really only gives time from end of July to end of November to prepare for exams or wait till the next year round. My suggestion would be to find someone who has done the primaries before and get the lecture notes from them so at least you can have a head start of things. -Focussing on study is difficult but not impossible. It is best to remove distractions and structure your study times and breaks well. I have found that working to a timer is useful. have it counting down e.g in 30 minute blocks and every time it goes off you can have a short break. Make sure you stick to these! -Studying hard core and denying yourself reasonable breaks and days off is ...

Subgingival calculus as the name implies is out of sight and therefore can be difficult to locate and clean. In this case, out of sight doesn't mean out of mind as it is our responsibility to locate these deposits and clean the tooth surface during the patient's regular periodontal maintenance visit. Locating these deposits in the first place is the difficulty and this can become much more difficult after debridement has begun due to bleeding of gums. Below are some points on how to identify subgingival calculus. Supragingival calculus tends to be yellower, chalkier and rougher than the surrounding tooth structure. Once you know the proper shape of the tooth and root surface, any deviation is easy to identify as calculus. Drying the tooth will help differentiate the two surfaces. Subgingival calculus is often proximally related to supragingival calculus as the same poor oral hygiene practices that have led to one lead to the other. Areas where subgingival calculus is prese...

So there was a request to make a post on how to build healthy relationships with the staff at work. Admittedly i'm not the most socially tuned in person but you don't necessarily have to be a relationship superstar to build a healthy relationship with a coworker. Strategies and work dynamics are wildly different according to your position at work. Support staff, dental associates and practice owners all must have different approaches to interact with their coworkers to avoid friction and relationship breakdown. I will approach this post from a general point of view and as well from the view of the associate dentist and practice owner. It isn't mandatory to get along with everyone at work but if you intend on working at a place for some time or plan on not hating your job it really does help. Below are some thought's ive jotted down on the subject: General thoughts: Be honest: Humans have inbuilt bullshit detectors and lying breeds distrust which is a killer in any t...