1. What are the two most important experiences you have had this year and why?
One experience that became memorable started during a hygiene check completed on 7/19/22. It was in this appointment I met a patient who I will call JP. She had an extensive medical history and was coming to our clinic to discuss options regarding her teeth. JP was diagnosed with follicular thyroid carcinoma in 2016 and had a total thyroidectomy after which point she acquired vocal cord paralysis. JP had a tracheostomy tube placed shortly after. Her chief complaint was she wanted a better smile because all of her dental work was failing. JP’s saliva appeared thick and ropy and she had developed radiation caries creating an environment prone to dental caries. The existing dental work in her mouth consisted of three crowns, many resin restorations that were leaking, fractured, or presented with secondary decay. Due to the previous radiation therapy she had undergone, there was enamel erosion and dentin exposure in multiple teeth. She had teeth that were brittle, fractured and decayed. Some teeth brought her pain and she was eager to move forward. Impressions were taken, study models created, esthetic wax up completed, treatment plan presented and the journey began. We worked on her treatment plan in hopes to increase her functionality, confidence and overall well-being. This full mouth case involved much collaboration and taught me so much. Getting non-restorable teeth out was the first priority to rid of the infection present and associated pain. An interim partial was fabricated as we worked on the case. Caries excavation was completed determining which teeth would need root canals prior to crowns. Two root canals were completed with build ups and crown preps began. JP first presented with a deep anterior bite with eight and nine slightly retroclined; the plan was to open her vertical dimension of occlusion 2mm to make space and make her anterior esthetics ideal. Through this process I was able to work with multiple faculty on how they would approach and restore the case during the planning phase, endo, prep and provisional phase. In dentistry, there are numerous ways to approach a procedure, it is important to discuss cases with co-workers to gain different perspectives and achieve the best outcome for patients. The mandibular posterior was prepped and provisionalized, followed by the lower anterior. Next was the maxillary arch; JP was provisionalized at her new vertical and wore these temporaries for weeks to make sure she could function well at this new bite with no discrepancy. Great communication with the dental lab was also something I experienced in this case and learned from as they answered any question I had. Final crowns were cemented and adjusted. Patient came to the last adjustment appointment dressed up, new wig, make up, smiling ear to ear; her life was changed.
Another case that was important involved extractions and an attempt at ‘hero-dontics’. This patient was undergoing dialysis treatment, had Medicaid insurance and needed full mouth extractions. Initially, this patient was referred to an oral surgeon as he would be more comfortable through the procedure due to the amount of teeth involved. Unfortunately, many times during residency, Medicaid patients come back from oral surgeon consults and say “I can’t afford the anesthesia fee, can you just do it here?” This puts me at a crossroad and a decision needs to be made. The patient and I had a discussion and agreed to do a few teeth each visit. The third visit that the patient came in for extractions, he did not look well. Sitting in the chair he seemed out of it, sweaty and his left arm was 4x the size of his right. When asked if he felt okay, he would nod yes. His blood pressure was extremely elevated. Patient was advised that we weren’t going to proceed with surgery and he was escorted to the ER. Weeks later when I had called to reschedule him and got no answer. On the news was a story of him missing and when I called his phone days later, his mother answered. She stated that he had passed away from a dirt bike incident and his body was just found. In that moment, I had to hold it together and just thank God for the time I did share with this young man.
Both instances showed that we aren’t treating ‘just teeth’, but a whole person. Patients that share their lives with us and build relationships with us. So many aspects of dentistry were learned during my full mouth case and for this case, I learned you have to know your limits when treating patients. Dental insurance doesn’t always cover what’s needed and it’s up to us as their provider on how to proceed. It was ideal for him to get the extractions completed at an oral surgeon and we could have then started his dentures, but we chose against and he’s not here to complete his case. Knowing the signs of medical emergencies and when to not proceed with procedures is paramount.
2. Of the topics presented in Patient Care Conferences by your fellow residents, name two that will be important to how you practice dentistry in the future and why.
One journal club presentation focused on safety guidelines when treating pregnant patients in the dental office. This topic is touched on in dental school, but as we don’t treat these patients daily, it’s important to have a refresher and commit these guidelines to memory to ensure the proper care of the mother and unborn fetus. There are different safety guidelines for each trimester of pregnancy.
During the first trimester, dental treatment should be limited to prophylaxis and emergency treatment only. During this time, organogenesis is occurring which is a phase of embryonic development where organs are forming from different germ layers. This development period is crucial and dental treatment must be limited to prevent any potential abnormalities. Radiographs should be completely avoided during this time and oral hygiene education is important. The second trimester is considered the safest period for routine dental care with selective use of radiographs; avoid routine radiographs throughout entire pregnancy. Control of active oral disease, scaling and polishing as well as elective care is safe. In the third trimester is where short dental appointments with proper positioning are helpful. Patients should have the right hip elevated while lying suping to relieve pressure on the vena cava to prevent a decrease in cardiac output. Routine dental treatment is okay, avoiding elective care towards the end. This presentation went on to explain the medications that are safe for this patient group as well as precautions to take when administering local anesthetic etc. It is ideal for pregnant patients to come to the dental clinic with a clearance letter from their OBGYN with recommendations
and/or precautions to abide by while treating. This information will serve me throughout my dental career when seeing this patient population because it is important to rid the mother of emergent pain and discomfort while keeping their unborn child safe and educate them on safety precautions and when they can safely proceed with other dental needs. Another journal club presentation explained the use of dental antibiotics and guidelines on when to prescribe them effectively and efficiently. At times, dentists are known to “overprescribe” antibiotics which could lead to other issues in the human body such as antimicrobial resistance. It was stated that antibiotics were seen as the ‘drug of fear’. Prescribers prescribe antibiotics to cover claims of negligence without scientific evidence, prescribe based off of old evidence rather than real indication and also patient requests. It was discussed that current guidelines for healthy ASA 1 and 2 patients, even when invasive procedures are completed, there isn’t an indication for antibiotics. Indications for prescribing prophylactic antibiotics include patients with history of infective endocarditis, prosthetic valves and unrepaired congenital heart defects. Antibiotic prescriptions are appropriate for immunocompromised patients with systemic disease (ASA 3+) and patients with history of radiation and/or bisphosphonates. There is controversy and differing opinions when it comes to artificial joints. The ADA states there is no indication unless the joint was placed within the last three months or the patient has had previous complications/ infections with joint replacement. This topic is important to remember throughout my dental career as I want to effectively prescribe antibiotics to patients. I do not want to overprescribe and I want to keep up with guidelines regarding this topic, as they could change throughout my career.
3. How has the past year in residency program changed you both personally and professionally?
When I first entered this residency, I was extremely nervous but eager to get started knowing there was so much to learn. I knew the bare minimum that I had acquired in dental school and had no experience with hospital dentistry. I had no idea that the patient base here would be so diverse and I would have the opportunity to meet and treat people of all different walks of life with unlimited medical histories. In the first few months, this program provided me with an amazing foundation in many different clinical procedures as well as didactic knowledge in subjects such as dental clearance for liver transplant, kidney transplant, clearing patients for head and neck radiation and/or chemotherapy etc. Learning to manage my operatory, schedule and work alongside my assistant was a learning curve for me but as the year has gone by, I’ve realized that I am respected in my role as a dentist and I perform well due to the ‘behind the scenes’ work that my assistant and office team complete. Time management is a huge part of my work day; learning how to strategically double book as well as complete hygiene checks, while staying on time and providing patients with the best care. This program has allowed me to come out of my shell both personally and professionally. There are times where I need to pick up the phone and call my patients for information and I feel comfortable doing that now as my communication skills have drastically improved. I’ve learned so much about every aspect of dentistry here and can now explain procedures and the ‘why’ of treatment plans much more effectively. Patient management was something I was nervous to tackle, but with this program, I have gained advice on how to handle difficult patients and comfort really nervous patients as well.
The resident faculty in this program and the adjunct faculty that volunteer their time to aid us through the year have been nothing short of incredible. In dental school I completed two
dentures, four partials, seven crowns and about fifteen extractions. Those requirements weren’t enough for me to know what I’m doing and what to do when the situation wasn’t ideal. Asking faculty to come into my appointments and teach me pearls and processes has increased my procedure ability tenfold. I’ve been able to troubleshoot when things aren’t ideal due to them showing me how they approach difficult situations and I now have the ability to complete surgical extractions with confidence, lay flaps, complete bone graft procedures, place implants; the opportunities this residency has provided me are endless. I love the see one, teach one, do one method and I have tried to live by that this year. Throughout the months, I’ve wanted to hear every word a faculty says whether it’s teaching me during a case or another resident in their own appointment, I would stand in the doorway and just soak in the information. I feel like that has served me well because you can never know too much. This career is a life-long learning journey and keeping an open mind and gaining different perspectives will aid me in future success. I have learned so much about complex treatment planning and gaining confidence in my clinical decisions. Diving into things such as Invisalign, 3D printing, completing root canals, full mouth rehab and placing implants are things I didn’t think I would be comfortable completing one year out of dental school, but I owe it to this program and the people that I am surrounded by every day. This past year has provided me with opportunities that I can build off of as I move to the west coast and start my professional dental career there. Because of this program, I am confident. I am ready.
A special thank you to Dr. McMillan, Dr. Hardin, Dr. Bodenner, all of the adjunct faculty and every professional I’ve come across in all of my rotations. I am who I am today, because of you.