Clinical tips to manage your clinical time:

5 Clinical tips to manage your clinical time:

1.Always start with lab.
Check if they are finished the clinical request before confirm patient appointment (for example: preparing custom tray, preparing record bases & occlusal rims…etc.)

2. Review your textbook before you come to the clinic … just the steps which you are tend to do it in the selective patient visit
if you have any doubt about any specific step ask your instructor before the date of the patient appointment.
Then follow his recommendation & if you fail in doing the step ask him to help you.

3. Prepare & setup all equipment’s you will need it & you will use it before allowing to the patient enter the clinic.

4. Always work with assistant (don’t work alone) especially in prostho.

5.Always remember that prostho is time consuming procedure which means that you should always manage your time to archive required results


To  gain the patient trust as well as satisfaction
GOOD LUCK

By Dr. Abdulrahman Ahmed Abu Zomer

pulp polyp

pulp polyp

Pulp Polyp, also called as Chronic Hyperplastic Pulpitis, or Proliferative pulpitis is a productive pulpal inflammation due to extensive carious exposure of any young pulpal tissue. This is a type of irreversible pulpitis, which is chronic and usually asymptomatic in nature.
It is characterized by development of granulation tissue, covered by epithelium and it results from irritation for a long time.

Causes of Pulp Polyp

• Dental caries in young tooth where significant loss of tooth is seen.

• Fractured tooth, causing trauma to the pulpal tissues.

• Mechanical irritation from chewing, and bacterial irritation provides stimulus.

Symptoms of Pulp Polyp

• They are asymptomatic, and sometimes the masticatory stress can lead to some tenderness.

• Sometimes, localized bleeding may occur.

• The polyps cover the entire cavity by enlarging itself.

Diagnosis

• Appearance of Polypoid tissue – A fleshy, reddish mass fills most of the pulp chamber or extends beyond the tooth structure.

• Polypoid tissue is less responsive when compared to normal pulp tissue.

• Radiographs show a large, open cavity with direct access to the pulp chamber.

• Response is seen on electric pulp testing too.

Treatment

Removal of the polypoid tissue, followed by the extirpation of the pulp. When the pulpal mass is removed, bleeding can be controlled by application of pressure. Formocresol dressing is placed after the entire pulp is removed.

Hypertenssion Patient in dental treatment

Hypertension Patient

Hypertensive patients should have their BP taken prior to significant dental procedures. Although an extensive review by Bader et al. (2002) concluded that epinephrine in local anesthetic VERY rarely resulted in adverse outcomes, many practitioners believe that hypertensive patients should receive no more than 0.04mg of epinephrine. However, remember the importance of pain control when treating hypertensive patients, as it will increase BP significantly.

 

Complications of antihypertensive treatment in orthostatic hypotension, xerostomia, dry mouth, gingival overgrowth, lichenoid reactions, and burning mouth symptoms. It is also important to be aware of patients taking non-potassium sparing diuretics, as epinephrine use can potentially decrease potassium, leading to dysrhythmias. Also, long term use of NSAIDs by decrease the effectiveness of certain antihypertensive agents; this is less of a problem with short term NSAID use.

 

Drug Interactions & Contraindications

Drug Interactions

 

In general, we should avoid polypharmacy and never prescribe anything without being aware of the patient‘s full medical history and current medications.
It is our responsibility to look up any possible interactions with the drugs that we prescribe. Epocrates is Dr. Flynn‘s preference.

 

 

 

Contraindicated Drugs in:

 

Patients with liver disease	Patients with kidney disease	Pregnant patients	Patients that are breast feeding
Aspirin Benzodiazepines Opioids Sedatives Anti-histamines NSAIDS Erythromycin Metronidazole Tetracycline	Acyclovir Penicillin Opioids Cephalosporins Benzodiazepines NSAIDS Tetracyclines Amphotericin	Aspirin Benzodiazepines Carbamazepine Opioids Cotrimoxazole NSAIDS Metronidazole Tetracyclines	Antihistamines Aspirin Benzodiazepines Carbamazepine Cotrimoxazole Metronidazole Tetracyclines

 

 

How to write prescription ? - and Analgesics

 

How to write prescription ? 

§  Date

§  Patient Name, age and contact info

§  Rx: name of drug and dosage

§  Disp: amount to provide (example, number of pills)

§  Sig: Directions (include what route of administration, dosage, frequency, max dose if relevant)

§  Refills, if any

§  Signature

§  DEA# for schedule II drugs

Abbreviations:

§  QD (quaque dies): every day

§  BID (bis in die): twice per day

§  TID (ter in die): thrice per day

§  QID (quater in die): four times per day

§  H (hora): hour

§  Q (quaque): every

§  HS (hora somni): at bedtime

§  NPO (nil per os): nothing by mouth

§  PO (per os): by mouth

§  PRN (pro re nata): as needed

§  Sig (signa): label, or let it be printed

 

Oral Pain (Analgesics)

 

Mild:  use OTC medications in suggested doses

Ÿ Ibuprofen (Advil/Motrin): 400mg (2 pills) PO q4-6h PRN pain, max 3.2g/day

Ÿ Acetaminophen (Tylenol): 325-650mg PO q4h PRN pain, max 4g/day

Ÿ Naproxen sodium (Aleve): 220-440mg PO q8-12h PRN pain, max 1.5g/day

Ÿ Aspirin (Ecotrin): 325-650mg PO q4h prn pain, max 4g/day

 

Moderate

Ÿ Ibuprofen: 800mg ibuprofen (see below)

Ÿ Tylenol #3: 300mg acetaminophen and 30mg Codeine
      (equianalgesic to 600 mg of ibuprofen, so why use it instead of ibuprofen? Says Dr. Flynn)

Ÿ Vicodin: 500mg acetaminophen and 5mg hydrocodone

Ÿ Vicoprofen: 200mg ibuprofen and 7.5mg hydrocodone (for patients with liver disease)

Ibuprofen (800mg) Disp: 20 (Twenty) tablets Sig: Take 1 tab PO qid PRN pain, max 4 tabs/day

Tylenol #3 (300mg/30mg) Disp: 20 (Twenty) tablets Sig: Take 1-2 tabs PO q4-6h PRN pain

Vicodin (500mg/5mg) Disp: 20 (Twenty) tablets Sig: Take 1-2 tabs PO q4-6h PRN pain, max 8 tabs/day

Vicoprofen (200mg/7.5mg) Disp: 20 (Twenty) tablets Sig: Take 1 tab PO q4-6h PRN pain, max 5 tabs/day

 

 

Severe

Ÿ Percocet: 325mg acetaminophen and 5mg oxycodone, schedule II

Ÿ Combunox: 400mg ibuprofen and 5mg oxycodone, schedule II (for patients with liver disease)

Ÿ Demerol: 50mg meperidine, schedule II

Percocet (325mg/5mg) Disp: 20 (Twenty) tablets Sig: Take 1 tab PO q4-6h PRN pain

Combunox (400mg/5mg) Disp: 20 (Twenty) tablets Sig: Take 1 tabs PO qid PRN pain, max 4 tabs/day, max 7 days

Demerol 50mg Disp: 20 (Twenty) tablets Sig: Take 1 tab PO q4h PRN pain, max 6 tabs/day

Extraction of non-restorable Retained Root - extraction

Extraction of non-restorable Retained Root

 

Indication For extraction : Non restorable tooth

Steps to put on personal barriers:
Mask and goggles  gown  wash hands 

GLOVES!!!

 

 

How to do simple tooth Extraction ?

 

 

1. Test the effectiveness of local anesthesia with the pointed end of a periosteal elevator.

2. Sever the gingivodental fibers with the same end of the periosteal elevator.

3. Elevate the tooth (never use an elevator on the lingual side of a tooth)

a. Small straight elevator: Insert the elevator into the mesial or distal PDL space with firm apical pressure, with the concave side toward the tooth to be extracted. Rotate the elevator in such a way as to move the tooth toward the facial.

b. Large straight elevator: Use the same technique to obtain a greater amount of movement. This instrument may be too large for small teeth, such as lower incisors.

c. Offset elevator: Maxillary third molars

d. Cryers: Left or Right, to get to a section of a tooth

e. Davis: double ended to get tiny roots out.

4. Luxate and extract

a. Forceps selection

i. Upper universal  – any upper tooth, small one for pediatric patients

ii. Lower universal  – any lower tooth, small for pediatric patients

iii. Cowhorn – lower molars with fairly straight non-fused roots

iv. Ash (various sized) – lower anteriors and bicuspids

v. Anatomic upper molar forceps  – for upper molars with non-fused roots.

b. Forceps placement: Keep the beaks in the long axis of the tooth and between the free gingiva and the tooth. Seat the forceps as apical as possible (keeps center of rotation apical, minimizes root fracture). Squeeze hard enough that the beaks do not slip when you luxate the tooth.

c. CONSTANT FIRM APICAL PRESSURE during luxation – converts the center of rotation of the tooth from the apical third to the apex. Prevents broken root tips.

d. Directions of luxation: Take your time; let the bone of the socket expand.

i. Upper anteriors – rotate in the long axis of the tooth

ii. Upper bicuspids – luxate to the buccal until you feel a loss of resistance, then PULL. Protect the lower teeth from injury if the tooth comes out suddenly. Only tooth you pull!

 

 

iii. Upper 1st and 2nd molars – buccal luxation

iv. Upper 3rd molars – buccal and distal luxation

 

 

v. Lower anteriors and bicuspids – rotate in the long axis of the tooth. A little bit of buccal luxation is okay for canines and bicuspids.

vi. Lower molars – Can opener or pump handle; buccal luxation motions in that order for extraction of lower molars using cowhorn forceps

5. Examine the root for complete extraction.

6. Carefully palpate the apical region with a curette.

a. To check for oro-antral communication (upper posteriors)

b. To check for and then remove periapical granulation tissue or cyst.

7. Remove periodontal granulation tissue with a Lucas curette and/or rongeur.

8. Palpate the alveolar process for sharp edges and undercuts , Perform alveoloplasty as necessary.

9. Suture the gingival tissues if necessary.

10. Place gauze dressing. Check for hemostasis before dismissing the patient.

11. Give postop instructions, analgesic prescription, and follow-up appointment if necessary

Abrasion

Abrasion

physical wear of a tooth caused by an external agent. classically , toothbrushs are blamed for characteristic cervical notches, but it is now believed that other factores may also be operating. Abfraction lessions are now typically tought to be due to flexutre of teeth under under excursive occlusal loading, possiblycoupled with some form of stress corrosion.

Root Resorption

Root Resorption

External root resorption  ( Caused by attachment damage, Periodontal defect.)


1. Surface root resorption (SRR)  - Transient, self limiting, reversible.
· Mechanical damage to cementum and disruption of PDLàdiscontinuous lamina dura.
· Clinically asymptomatic. Pulp is generally vital, repair usually occurs within 14 days.
· No tx indicated.
 
2. Inflammatory resorption  -
Surface inflammatory resorption (IRR) -  Necrotic pulp with bacteria in tubules is the stimulus for continued resorption of dentin after cementum resorbed due to attachment damage. Generally occurs in the apical and lateral aspects of the root.
· Radiographically looks like moth eaten resorption defects of cementum and dentin.
· Clinically asymptomatic, but PULP is NECROTIC.
· Treatment involves removing pulp and placing and replacing calcium hydroxide medicament to remove bacteria and toxins in dentinal tubules and stop process. This treatment is only sometimes effective in stopping the process.
 
· Cervical inflammatory resorption (CRR) – ( Results from sulcular infection caused by trauma (ortho, aggressive scaling), non-vital bleaching or unknown. )
· Radiographically appears as bony defect and radiolucency around cervical area of tooth; may be confused with cervical caries or burnout. If it is located on the buccal or lingual CEJ region, appears as a hazy radiolucency overlapping the well defined pulp chamber (how you can differentiate from internal root resorption).
· Clinically the tooth may look pink and have a crestal bony defect. PULP is generally VITAL or has been RCT treated (not necrotic).
· Treatment involves flapping to expose lesion, surgical removal of granulation tissue and placing glass ionomer restoration.
 
3. Replacement resorption (ankylosis) (RRR) - Caused by damage to and disruption of PDL, often after reimplantation of teeth or in some primary teeth. Cementum replaced with bone, then dentin replaced with bone.
· Radiographically loss of lamina dura and fusing of bone and tooth is evident. Often leads to infraocclusion. Located on lateral and apical aspects of root and generally continues until whole root replaced with bone and crown decoronates.
· Clinically, percussion of the tooth produces a high-pitched metallic sound, and the tooth may be in infraocclusion.
· No treatment is indicated or has been shown to stop progression or eventual loss of the tooth.
· Sometimes this is a goal of reimplanting a tooth to allow for a nice implant site later. To encourage ankylosis, before implating the tooth scrub off all the PDL cells or place the tooth in acid to ensure their death.
· *Most people use RRR and ankylosis interchangeably, but RRR refers to the resorptive process and ankylosis refers to the end result.

Internal root resorption – ( Caused by pulp , Root canal defect. )
- Pulpal inflammation caused by caries, attrition, cracks, trauma, deep preparations or trauma stimulates odontoclastic cells to resorb dentin inside the tooth. Relatively rare, especially in permanent teeth. Process continues as long as there are vital cells in the pulp.
- Radiographically appears as enlargement of pulp canals or chamber with altered irregular anatomy.
- Clinically, is usually asymptomatic, and picked up on routine radiographs. Tooth tests vital. If the resorption is in the coronal part of the tooth, it may look pink.
- Treatment: prompt endodontic therapy (2 visit) is highly successful in stopping the process, and the tooth has a good prognosis is the resportion is caught early and the defect is small.
 
 

 

Generalized gingivitis - Gingival Disease

Generalized Gingivitis - Gingival Diseases

Chronic gingivitis is an inflamation of the gingival tissues. it is not associated with alveolar bone resorption or apical migration of the junctional epithelium .Pockets >2mm can occurein chronic gingivitis due to an increase in gingival size because of oedema or hyperplasia ( false Pockets ). Different types of gingivitis are described , the commonest type is plaque induced.

Plaque induced gingivitis, Present in virtually all mouths to some extent. The Classic triade of redness, swelling, and bleeding on gentle probingare the diagnostic and are usually associated with a complaint by the patient that the ' gums bleed on brushing. False pocket may also be present.

Inflamatory changes are easily reversible after institution of effective plaque control. while gingivitis is revesible, it should be remembered that calculus and other factores which promote plaque retention (e.g. overhanging restorations) will make adequate oral hygiene diffecult. these factors therefore should be corrected by scaling and appropriate restorative treatment in addition to oral hygiene instruction.

Other types : Gingivitis modifid by systemic factors ,  Gingivitis modifid by medications.

Rx. Done: Full mouth scaling, prophylaxis, patient education & OHI.  

 

 

 

Orthodontics Wires

 
Orthodontics Wires : ( Special thanks to Dr.Ranjana )
           In the beginning stages of treatment, round wires are typically used to align the teeth. This is because round wires are more elastic and so the orthodontist will be able to engage all your teeth into the wire without popping off brackets. 

         If he uses a wire that is too stiff and tries to tie the arch wire to a really crooked tooth, the wire will put too much pressure on the bracket, and the bracket may break off from the tooth.

             
 After the teeth are straighter, orthodontists usually advance to rectangular wires. Because the wire slot of the bracket is rectangular, a rectangular wire fits into the bracket like a hand fits into a glove. 

       
In the beginning, the smaller rectangular wire may be like a small hand in a large glove. However, by the end of treatment, the rectangular wire you have may be more like a large hand in a large glove. By fitting snugly into the bracket, the rectangular wire controls tooth movement better than a round wire.


Arch Wire Materials: 
1) Stainless steel
2) Nickel titanium (Ni-Ti)
3) Beta titanium

      1) Stainless steel wires

have been used for decades due to their high strength. In addition, stainless steel wires do not rust and can be adjusted many different ways by the orthodontist without breaking.
However, stainless steel wires are not very elastic, meaning that if you bend these wires too much, they will assume the new position and will not return to their original position. In the beginning stages of treatment, it is important for the wires to be elastic so that the wires can bounce back to a nice smooth U-shape and carry the teeth with it at the same time.
So as you can see, in the initial stages of aligning very crooked teeth, stainless steel wires may not be the best option.

2) Nickel-Titanium (Ni-Ti) wires  are elastic and can return to their original shape when deformed. Therefore, in the beginning stages of orthodontic treatment, Ni-Ti wires are frequently used to put gentle forces on the crooked teeth to align them. A variation of Ni-Ti wires are heat-activated Ni-Ti (Copper Ni-Ti) wires. Heat-activated Ni-Ti wires can hold the deformed configuration at room temperate, but when the wire reaches the temperature of a patient’s mouth, the wire will return to its original shape. Heat-activated Ni-Ti wires are useful in the beginning stages of treatment. If the teeth are extremely crooked, the wire can be cooled so it can be tied into the brackets easier. Then after a few minutes, it will reach the temperature of the patient’s mouth, displaying its Ni-Ti elastic properties. The warm wire will want to assume its original U-shape and carry the teeth to their new, straighter positions.

3) Beta-Titanium wires were developed after Ni-Ti wires and offer an intermediate range of elasticity and strength, while also being able to be permanently deformed. This wire serves as a good intermediary wire between  Ni-Ti and stainless steel.  Some orthodontists will use this wire starting in the middle of treatment while other orthodontists do not use this type of wire at all.


Which wire to Use ??? 
Some orthodontists only use Ni-Ti wires while other orthodontists only use stainless steel wires. However, most orthodontists typically start with small Ni-Ti wires to align crooked teeth in the beginning, and progress to larger Stainless Steel or Beta-Titanium wires when more control of teeth is necessary.