The past two months I have been flying back to KL frequently
for courses, workshop and conferences. In my opinion, continue professional
development is very important as a dental professional to keep up with the
evolving knowledge and skills in dentistry. As a junior dentist, I find this is
a good means to fill up the knowledge gap holes and improve my clinical skills
beyond the trainings I received back in dental school. I believe the initial
clinical years are the building blocks to become a successful holistic dental
surgeon and this will involve a lot of self-initiative knowledge seeking and
skills upgrading. This blog post will be a summary of what I have pick up
during those meetings that I have joined. Hopefully it will be beneficial to
others.
(Warning: It's going to be a long post! )
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| I learned that goats have fused posterior teeth and only have lower anteriors |
Ever since working on my first endo molar case in primary
care, I find myself lacking in periodontics surgical skills and management. My
undergrad perio logbook was full with hands scaling, ultrasonic scaling and
root planning quotas but I was only required to complete only one perio
surgical case. I had a hard time finding for a patient to agree on a perio surgery.
In the end, my chair neighbor from across ‘shared’ her patient with me and my chair
mate. Under the constant guidance of my perio HOD, we completed the flap
surgery. I did not develop enough concern for periodontics at that time and
never gave a thought to explore more into periodontal surgeries up until that
endo molar case.
That molar came to me after it have repetitive episodes of
abscess and I saw it when the abscess had obliterated the buccal sulcus. The tooth
was Grade 2 mobile and have a slightly extensive disto occlusal caries.
Interestingly, this patient did not have a second molar and the patient wanted
to keep that tooth. After all my investigations, this was truly what we have
read in textbooks: Primary endo secondary perio lesion. Although I should have been
more worried about the C- shaped canal configuration but instead I felt
helpless to handle the perio component of the tooth. All I could offer at the
moment was just supragingival scaling and root planning to treat the perio
lesion. It was then I felt to need to seek guidance and training in a
comprehensive periodontic management and its surgical skills. Thank God, my
junior Esther shared a facebook post on the periodontic course and after much
considerations, I enrolled myself for it. One thing I should point out about
working in Borneo is that it is quite a hassle to join courses or workshop in
KL as extra travelling time and transportation expenses are involved and these
two factors can be quite demotivating.
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| With Dr Sowmya <3 |
The course coordinator was Dr Sowmya who happens to be my
periodontics lecturer back in UG days. It was a four days course which was
conducted on two weekends. I literally flew back to Sarawak to work for 3 days
and then flew back to KL to finished up the second half of the course. Having
say that, I was thankful to have attended it. The course touched on many
aspects of managing periodontal lesions and clinical tips on perio surgical
skills. I love how the course was designed in a way that it gradually
acclimatized us from simple suturing techniques to more advance regenerative
surgeries and palatal graft harvesting.
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| First step: Placing proper sutures |
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| Sutures should run on the middle of the base of the interdental papilla. |
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| Apically repositioned flap |
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| The bone graft that we 'played' with |
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| Regenerative Osseous Surgery checked! |
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| Harvesting the Palatal Free Gingival Autograft |
Here is a summary of the concepts I
have grasp from the course:
1.
Most periodontal disease are painless and
therefore pt only take concern when something significant happen to their teeth
(change of color, arrangement, mobility). Clinicians on the other hand don’t
pay much attention because they are unsure how to manage this multifactorial
disease.
2.
Stress is one of the factor that can bring about
the disease progression (besides systemic, genetic, environmental and social
factors) and hence if you come to know that your pt is stressed out, it would
be good to point out to them that destressing will improve the overall outcome
of the treatment.
3.
The fixed property of the attached gingiva is
important not only for toothbrush placement as well as preventing food packing
into the sulcus which in its absence is surrounded by freely movable marginal
gingival. This doesn’t means if the pt doesn’t have attached gingival we need
to advice vestibuloplasty as they might still be able to maintain good hygiene.
4.
Smokers are likely to complain that they
experience bleeding gums after your periodontal therapy as the gingival that
was once clogged with cigarette byproduct leading to vasoconstriction is now
undergoing repair and vasodilates. Its best to foreworn the pt that bleeding
indicate the gingival is coming back to health.
5.
It is usual that the interdental papilla gets
inflamed first because food impactions commonly starts at the contact point.
This may progress to produce unaesthetic black triangle. A symptom of food impaction is that the pt
will claim that the teeth feels better when they bite down.
6.
Crown lengthening procedure ≠
Gingivectomy. Crown lengthening procedure can either be gingivectomy OR a
simple osteotomy and choosing between the two depends on the tooth biological
width.
7.
Pt who have a pacemaker, make note of the type
of pacemaker they have. If it’s non-shielded type, it’s a no no to use ultrasonic
scaler.
8.
The duration of the flap surgery is crucial as
the longer time it takes, the more bone resorption and remodeling will occur.
Try maintaining less than an hour per quadrant.
9.
Best irrigating solution during the surgery is
isotonic saline as it produces the best post-op tissue healing. Chlorhexidine
if used is taken up by the cells through osmosis and since is not isotonic, the
cells tends to burst and apoptosis occur, slowing down the healing process.
10.
It’s important to tissue condition (scaling,
root planning and splinting for mobile teeth) before a flap surgery to decrease
the inflammation of the gingival and achieve a firmer tissue to be incise. The
pocket depth of 6mm might decrease to 4mm after tissue conditioning but it is
not consider to heal completely as there is still unhealthy granulation tissue
present within that can continue to cause bone loss and hence flap surgery is
still necessary.
11.
Never place your vertical incision over the root
surface of the tooth as the bone over the root is thinner than interdentally
and more bone resorption might occur during healing leading to fenestration.
12.
Split thickness flap is only used if the pt have
thick gingiva biotype.
13.
You may only probe around the tooth after 1
month of the flap surgery as this might disturb the healing process and the
passive attachment of the long junctional epithelium.
14.
Always try to coronally advanced the flap as the
flap tends to shrink during the healing process.
15.
Do not offer regenerative osseous surgery in
horizontal bone loss case as there is no place that you can pack your bone
graft. You may only do a flap surgery for debridement to preserve the existing
precious bone levels. Therefore, it is necessary to take a pre-op radiograph to
assess the type of bone loss before proceeding with treatment planning
16.
Accurate assessment of angular bone loss can be
only done after you have raise the flap. (You may also map out the bone loss by
performing transgingival probing or also known as bone sounding under LA.) You should
inform pt pre-op that you will raise the flap, debride the area and then assess
how many walls are remaining. Let the pt know that there might be chance that
you might be able to place the bone graft and how much that will cost.
17.
The best graft is the autogenous graft as they
have osteogenesis, osteoinduction as well as osteoconduction properties. This
is follow by the allografts and then the xenograft. The xenograft gives good
osteoconduction and little osteoinduction properties. The alloplasts (which are
synthetic graft made of porous hydroxyapatite crystals) only acts as fillers at
the defect site and have no regenerative properties.
18.
Support and stability of the graft placed is
obtained by placing a membrane over the graft to prevent gingiva contact with
the bone, allowing time for the pleuripotent PDL cells to generate into
fibroblasts, cementoblasts and osteoblasts, avoiding epithelium to fill the
defect and form the long junctional epithelium. This is why the procedure is
named as Guided Tissue Regeneration.
19.
The membrane places should never have sharp
edges and should extend to all sides of the graft. The membrane placed should
never be folded and must be laying over the graft in a single sheet.
20.
It is important to achieve a tension free
closure so that the membrane stays in place. Tension flap will cause the
membrane to stick out of the flap margins after 1 day post op.
As a whole, the course was very organized and enjoyable. It
was definitely nice to execute the techniques learned on the goat jaws directly
after the theory lectures with the guidance of Dr Sowmya herself. Since it was
a small group, everyone got to interact with each other and we all had a great time
learning together.
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| Smelling mutton fumes together |
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| Proudly completed the course! |
Few weeks following that, I also signed up for the MAAD 14th
Scientific Conference and Workshop. The workshop coordinator was Prof Dr Subir
Banerji from King’s College London who dealt on the subject of minimally
invasive anterior aesthetic restorations. It was a full day hands on learning
about direct composite veneers and cutting predictable anterior ceramic veneers
held in FOD UiTM Sg Buloh. Prof Subir started the day having us to download an
app in order we can participate in the polls which he had prepared. The app
also allowed us to post our doubts and questions in the middle of his
presentation which I thought was quite clever and considerate for those who are
shy to speak out. Besides that, he did bring to light a new concept of
Reflective Axial Tooth Movement or also known as the Dahl phenomena which
stirred the floor that day.
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| Convincing us to downloading the app (Photo taken from MAAD FB Page) |
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| Direct composite veneer learning set! |
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| TIP! Shape the composite on the pad first before placing it on the tooth |
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| Finished product! |
The following are what I have picked up from the workshop:
1.
Esthetic value of your restoration is determined
by shade, surface morphology or contour, the material characteristics, the
ability to mask discolorations and usage of tints.
2.
Shade selection shouldn’t rely on existing shade
guide. Instead, select the shade by placing composite on the unetched tooth
surface to verify the correct shade.
3.
Try to minimize the habit of building bulky
composite restoration and burring it down after you have cure it. This can destroy
all the surface characteristics and cause more time to finish and polish the
restoration. Instead, build and shape the composite restoration to the desired
final appearance before curing.
4.
Morphology like indentations and line angles
affect the reflection of lights off your restoration which help it to appear
more natural looking. Flat surface is very unaesthetic.
5.
Remember achieving the perfect smile is NOT for
everyone. Some pt just want improvement of their smile.
6.
Anything besides your natural tooth have a shelf
life. The natural tooth is the best bet for longevity. Usually if a crown or
veneer is placed after much tooth structure is cut down, the tooth itself tends
to fail. If something is healthy, leave it be.
7.
Esthetic is not static but dynamic. There is always
physiologic wear and tear and the natural tooth color changes with age. Placing
a single anterior ceramic veneer with the adjacent 5 natural anteriors can over
time turn unaesthetic as the natural teeth color will change as the pt ages and
the ceramic veneer remains the same.
8.
2 things that are predictable in dentistry are
osteointergration and enamel bonding on clean enamel. To clean the enamel
before etching, you can air abrade it with 14 micrometer particles or clean
using pumice slurry with bristle brush. Enamel bonding is say to have failed if
stains is seen along the edge of the composite during review visit.
9.
Etching, washing and bonding timings are very
important and should be strictly followed for proper bonding to occur.
10.
Post op sensitivity is usually due to unsettle
bonding agent in the depth of the cavity.
11.
When shaping and contouring the composite
restoration, try to use short gentle taps with your instrument on the composite
to prevent the composite from sticking onto your instrument.
12.
When shaping the composite, analyze your
restoration in all 3 dimensions.
13.
If you are using a paintbrush to help shaping
your restoration, use it dry without dipping it into bonding agent as the
bonding agent have low strength and can chip off easily leaving rooms for
staining to occur.
14.
For diastema closure, the teeth usually end up
looking longer. To help the pt picture this, diagnostic wax up as well as
provisional intraoral build up should be done before planning the final restoration.
Overall the workshop has been
quite educational and enjoyable for me. I got to bring home the Shofu products
we used during the workshop.
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| Ceramic Veneer Learning Set |
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| Playing with the provisional crown material! Haven't touch that since I graduated. (Photo taken from MAAD FB Page) |
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| And that's a wrap! (Photo taken from MAAD FB Page) |
I also attended the conference held in Intercontinental
Hotel KL the next day. As there were some road closure in KL due to the
Standard Charter Marathon, my friend Shirley and I had to take an hour LRT
journey to the venue. There were still many vacant seats in the spacious dark
hall as the talk by Prof Subir started. The low turnout rates this year might
be due to the fact most junior dentists that made out the crowd last year had
been absorbed into the workforce and are posted throughout the country. Once again
Prof Subir got the floor to answer his polls through the same app and he gave
his presentation on Aesthetic Dentistry – The Challenges. From his polls,
almost everyone agreed that there is an increase demand for aesthetic treatment
outcomes from patients these days. He did point out that the concept of
esthetic and beauty are intimately related and vary within and between
different cultures, ethnic and age groups. We should carefully asses the
patient expectations and careful not to imposed our own interpretations of a
perfect smile. Besides that, he once again highlighted that minimally invasion
in healthy tooth structure would give us the best long-term predictability of
the tooth.
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| Had to take a photo with the big board |
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| From Dr Subir's slides |
The second speaker for the day was Dr Fidaus Hariri who presented
about 10 clinical cases of cranio-maxillofacial surgery done in pts with facial
defects. It was quite humbling to see his work and also reminded how blessed I am.
Following lunch, Dr Ronnie Yap brought us through his presentation of Marketing
Aesthetic Dentistry in your Practice: Increasing Clinical Acceptance. He
highlighted branding is subconscious with his witty slide of a plain blue shirt
with a printed Nike logo and the same shirt without the logo.
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| How much are you willing to pay for that shirt on the right? |
He shared many
tips on marketing your private dental practice, how everything you post on
social media impacts your personal branding and how the minor human touch like
giving them headphones with soothing music during the dental treatment can
change your patient perception of you. He also shared his experience in
tackling pts with common replies like “I need to think about it”, “I need to
check with my mother/husband” and “Dr, I trust you to decide best for me” as
well as communicating with clinical failure cases. It was a lesson of how to be
street smart with your patients and I really did gain a lot from his talk. I
was quite dishearten that he did not have enough time to finish up his entire
presentation. Hopefully the organizers would invite him again in the future.
The day ended with lucky draws and I won Dr Subir’s book ‘Practical
Procedures In Aesthetic Dentistry’!
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| Yes! Autograph from the author himself. (Photo courtesy of Bryan) |
That’s all for now. Hope you have benefited from this post.
