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EoghanIRL

Re replacing an amalgam mod...
Is it better to drill the restoration into sections and then push it out with a condenser etc..
or to drill it all away like a normal cavity preparation..

I would probably go with the first option , just wanted to see what others would do in this situation?

digzy

EoghanIRL wrote: »

Re replacing an amalgam mod...
Is it better to drill the restoration into sections and then push it out with a condenser etc..
or to drill it all away like a normal cavity preparation..

I would probably go with the first option , just wanted to see what others would do in this situation?

Best advice I could give for this one is to wear your glasses!

Big_G

When removing amalgam, it is best to reduce aerosol by touching the amalgam the minimum amount with the bur.  The shortest cut that will eliminate retention is what should be done.  I'm not aware of any studies that show whether cutting around the circumference of the restoration or sectioning it are the most effective.  I was taught in dental school to go around the outside and then pop the filling out.  This does not always work and sometimes section is required.

EoghanIRL

I found that a mixture of sectioning it and drilling along the amalgam tooth structure interface was required to remove it in the end.
Sectioning it by cutting a cross shape in the restoration wasn't enough to pop it out , but popped out almost immediately once cutting around circumference.

btkm8unsl0w5r4

Drill around the margins to release the undercuts, usually the box and bulk fly out. Carbides are usually more efficient than diamonds because the dont "clog up". The question is....is there a problem with the aerosol?

EoghanIRL

The list of drugs which cause xerostomia is vast to say the least... Obviously some drugs are classically associated with xerostomia but with some drugs it would make you think what the actual incidence of occurrence is..
For instance some diuretics give xerostomia as a side effect but then after getting a lecture from a physician who prescribes diuretics they said they have never come across this side effect...

Do you see drug induced xerostomia often in practice and is it usually confined to a small number of typical drugs?

Big_G

In the US polypharmacy is a much bigger problem than in Ireland. A recent pharmacology lecturer revealed that of the top 200 prescribed drugs in the US, 2/3rds can cause or contribute to xerostomia. I am quite regularly seeing patients with signs and symptoms of dry mouth and often the only possibility is pharmacologically induced xerostomia. Once you know what to look out for, you'll start seeing them more often. Doctors might not see it because they won't be watching for it and it also depends on wheter the pt is subjectively or objectively dry.

btkm8unsl0w5r4

I see a good bit of dry mouth. Usually poly-pharmacy induced. Often psychiatric meds. Next most common cause is age related. There is also the fact that the quality of the saliva can be effected with an abundance of serious and a lack of mucous saliva. The patients mouth is subjectively not dry but all the good protective stuff is not there....frothy saliva syndrome.

Fishorsealant

If a patient asks you not to include something they told you in their medical history , does this mean that you have to not make note of it even if it was an infectious disease?

Dianthus

Fishorsealant wrote: »

If a patient asks you not to include something they told you in their medical history , does this mean that you have to not make note of it even if it was an infectious disease?

I've had the same scenario arise & asked my indemnity organisation what their view was. Couldn't get a concrete response.
Theoretically, you're meant to treat *every* patient as though they have an infectious disease, so someone disclosing their diagnosis shouldn't make a difference in terms of cross infection control. However, it can impact on their treatment in other ways (meds, xerostomia, mood/behaviour, attendance, drug interactions, dietary habits, ect).
I would say to respect their wishes& not document it, as requested. But to get consent to reference something very very vague like "discussed with patient& requested no written record" on the chart (this could cover anything from adoption to depression to cancer, so wouldn't be betraying the pts confidence to anyone reading the notes but would still be a reminder to you the practitioner)
Also to reassure the patient that their medical history is completely confidential & won't be disclosed to any 3rd parties.
Tbh, particularly in the case of HIV, I'd be far more worried about the **undiagnosed** patients walking around, clueless as to their condition,& without treatment- highly infectious.

Fishorsealant

Hi dianthus, thanks for replying.

In the dental council code of practice it refers to in extreme circumstances protecting the public interest.

However with standard precautions and needle stick injury protocol it's hard to tell how much of a risk it poses.
Definitely contentious that's for sure!

What if you were working in a practice with multiple dentists across different specialities. Would it be appropriate to warn your colleagues of the infectious status of the patient if they were to treat them.

I think that the infectious status of the patient doesn't meet the criteria for protecting public interest. I feel protecting the public interest refers to something more serious in nature such as a child being kidnapped on your premise or child abuse etc
So I am leaning towards respecting the patients wishes and not breaching confidentiality.

Is this a grey area or is it black and white and I'm not seeing the answer?

Dianthus

Knowing the patients status should not make any difference to the public interest.
We are trained to treat every single patient as though they carry an infectious disease.
Equally, we are not allowed refuse to treat a patient because they have an infectious disease- it's considered discrimination.
Needlestick injuries have a standard set procedure & any reasonable& decent patient would disclose their status if asked after such an incident.

Fishorsealant

Preventive resin restorations or just placing a fissure sealant over a composite after placing, yes or no?

Some supervisors push yes some no...Have heard divided opinions on this

I dont really see the point in placing a fissure sealant over a composite if you have got a good hermetic seal anyway?

Maybe if patient had a filling and a deep fissure as well but I don't really see the point otherwise.

digzy

Fishorsealant wrote: »

Preventive resin restorations or just placing a fissure sealant over a composite after placing, yes or no?

Some supervisors push yes some no...Have heard divided opinions on this

I dont really see the point in placing a fissure sealant over a composite if you have got a good hermetic seal anyway?

Maybe if patient had a filling and a deep fissure as well but I don't really see the point otherwise.

If a supervisor is teaching students to place a fs over a composite they should be students themselves. I'm shocked.

Fishorsealant

I don't understand the reasoning behind it myself if I'm being honest.

btkm8unsl0w5r4

The thinking is that the cavity is so small there is no ability to control the C factor shrinkage, the layer of sealant (unfilled/lightly filled resin basically) flows into the shrinkage gaps at the margins and gives a better seal in a smaller bulk. As there was no extension for prevention either the sealant fills the adjacent fissures.

I do it to big composites when I dont obliterate the fissure, you can use a bit of bond to do it also these days with all the single bottle stuff. Its the same idea as using flowable in the box area.

Fishorsealant

When you are working unassisted and have a mirror in one hand and a handpiece in other how do you stop the patient from drowning with the water spray? Saliva ejector very limited water control I find.

btkm8unsl0w5r4

Ditch the mirror and use the high volume for retraction, move the patients head so you have direct vision. There is a real knack to doing it, but I find it sometimes easier on the left to hold the suction yourself (right handed operator). Patient positioning in the chair and getting them to tilt and move their heads is essential.

Saliva ejectors are of no use.

Fishorsealant

Removing a cusp during a filling.

When is it definitely the right decision?

I had a restoration where I followed ADJ laterally until I met enamel and then followed it downwards a bit. The cusp was quite undermined yet I still left it which got me thinking how would I have known to remove it completely...

davo10

You won't know for certain, you just have to make a call on it based on knowledge and intuition. There are so many variables such as strength of dentine/enamel, occlusion, diet etc. If you think it is going to break easily, either remove it or warn the patient. I'm more likely to retain thin cusps with composite fillings than I am with amalgam due to the bond, but every dentist will tell you even strong cusps break occasionally, and weak ones can be there for 20+ years.

btkm8unsl0w5r4

I always give the weak portion a good solid few taps with the flat end of a mirror along its weak axis, if its really weak it will break right off (warn patient your going to do this to avoid the "you broke my tooth" conversation.). If it survives the test then fill around it. As Davo said apart from that.

Dianthus

Use articulating paper to check the occlusion pre-op, not just post-op.
Also, sometimes you can do an "overlay" type restoration, versus removing the entire wall.

Fishorsealant

Was taking to someone who was working with a dentist and they told me that for fillings they would clear ADJ , leave base , place dycal and then use RMGIC as definite restoration.

Is this common?
Any RMGICs I placed I was always made restore them with composite before tx plan complete. I know RMGIC doesn't have as good long term performance...

btkm8unsl0w5r4

RMGIC tend to wear quite a lot on occlusal surfaces and they are a tad soluble. I wouldn't consider them definitive restorations on occlusal surfaces, Its a fine material for sandwich technique, Class 5 restorations etc.....having said that I have worked with a dentist who did this and said she would just cover it with composite later if it wore out. They all looked like a bag of crap to me but she swore by it. I always think the easy option is rarely the best.

Fishorsealant

If you were in practice and had a patient who needed supra gingival scale but was sensitive +++ would you give LA to all quadrants in one visit? Some patients experience a lot of sensitivity with the ultra sonic but at the same time it probably isn't a nice experience to have 4 quadrants numbed either.
Two visits needed?

davo10

It really depends on the extent of cleaning required and the patient. Usually the most sensitive areas are the lower anteriors and upper premolars/6's. Three cartridges will usually do the trick, use articaine so that a small amount will numb sufficiently for cleaning. You will often find that the time taken to numb the patient is offset by the shorter time taken to scale teeth in comfort. Also, we charge a higher fee for cleaning with LA.

Fishorsealant

Removed a composite filling and found a pulp exposure(small,no bleeding). This was before I removed any caries, just restoration removal.
Checked radiograph and filling didn't seem close to pulp. I know secondary caries and pulp is underestimated on radiograph but is this unusual?

Edit: there was a really bad smell coming from the composite when I removed it but not sure is this normal with certain brands?

btkm8unsl0w5r4

Small previous exposure probably killed the pulp and the smell is necrosis leaching into the restoration, hence no bleeding. You can hit a pulp horn without an extensive restoration. Yeah its very common. Goes to show, if you expose recommend endo. Exposure is a fact of the job, its nothing to feel bad about, unless your being careless.

Fishorsealant

A lot of people are mentioning pinhole surgery for recession defects. When I researched a Dr.Chao keeps coming up,seems a bit odd.
Does anyone know is this a legitimate procedure??

btkm8unsl0w5r4

Fishorsealant wrote: »

A lot of people are mentioning pinhole surgery for recession defects. When I researched a Dr.Chao keeps coming up,seems a bit odd.
Does anyone know is this a legitimate procedure??

No I looked into it and it seems legit. Its just a tunneling technique that he has developed special protocol and instruments for. Like all recession coverage it really depends on the defect, his own research shows about a 50% success rate.

Fishorsealant

When I graduate will I be expected to do basic surgical extractions?

If I work somewhere not close to a dental hospital and a tooth breaks when I'm doing a forceps extraction would it be expected that I lift a flap and remove some bone etc...?

Dianthus

You'd be expected to work within your capabilities, but also not to leave the patient at a disadvantage....
For this reason, I would strongly recommend to work in a practice with at least 2 other more experienced dentists on site for the first few years at least.
You might only need to call on them once or twice a year, but it's great backup to know they're around& can lend a hand if needed. Also it gives you the opportunity to shadow them/watch& learn more.
There's an OS on this forum who will be able to advise better, but there's a lot to be said for flapless extractions/sectioning roots. Avoids sutures, less trauma, more bone preservation.
& of course never ever attempt an impacted lower wisdom tooth!

Fishorsealant

Hi Dianthus.
I have seen enough wisdom tooth surgical extractions to know that haha.

People I have been talking to have told me that a lot of general dentists will do basic surgical extractions especially in places like Canada etc..
I don't know what the situation in Ireland is though.

Dianthus

Realistically you'll always need to have basic surgical skills alright. Narrow roots, curved roots, divergent roots, retained roots, extensively decayed teeth, bruxists.....the list is endless

davo10

I know they didn't allow students to use luxators/periotomes when I was training, but they are brilliant tools to have when you are faced with decoronated teeth. I rarely need to do surgical extractions, I'd prefer to spend a little longer with a luxator than remove bone, much better Ito preserve the buccal plate if the patient might want an implant down the line.

Impacted lower 8s are for OS's, even if you do a great job, the patient will still think you butchered them. Send them to an OS, they will thank you for leaving it to an expert.

Fishorsealant

If you have a long canal , say in a canine.
Guidelines say 7-8mm post length and 4mm GP left at apes.
If you have a long straight canal would you increase the length of the post? How do you know how long to make the post in this case? As long as possible I.e canal length minus 4mm?

davo10

Fishorsealant wrote: »

If you have a long canal , say in a canine.
Guidelines say 7-8mm post length and 4mm GP left at apes.
If you have a long straight canal would you increase the length of the post? How do you know how long to make the post in this case? As long as possible I.e canal length minus 4mm?

You have to use your judgement based on the length and morphology of the canal, personally I try to make the post at least as long as the crown.

I tend to prep the canal first with gates gladdens, then with parapost drills, starting with the narrowest and working up. I like threaded posts, I heard reknowned prosthodontists claim that both threaded and cast are better than one another.

My experience with carbon fibre posts has been poor, I don't use them at all now. But if you haven't tried luxacore resin core material, try it, it is fantastic stuff.

btkm8unsl0w5r4

Generally you make the post.
1. Below Bone level.
2. Leaving 3-5mm GP.
3. One third the width of the root.
If you can make it longer than the crown while following the above thats fine, if its shorter than the crown in order to avoid any of the above thats fine too.

Post material doesnt matter much in the presence of good ferrule. In the absence of ferrule cast posts are less prone to fracture. Customs cast posts and prefabricated posts show no differences. Parallel are preferred to tapered for root fracture reasons. Threaded or smooth doesnt matter. Flexure of the post doesnt matter (its the flexure of the cement that matters.

At the end of the day the best post is no post at all. The teeth that last 30 years with a post and core likely didnt need a post in the first place. The only reason to have a post is to retain a core, and if you can do that without a post then do that. After that use whatever works for you. I like glass fiber posts and titanium paraposts. I dont do any cast, as I feel once you think you need one the tooth is really in very poor nick.

davo10

I think it was Lloyd Searson who said at a lecture that he never did a post crown that he wasn't worried about it coming out. If it needs a post, prolonged retention of the tooth is a real bonus.

Fishorsealant

Does reducing the distal aspect of upper 6s and 7s get any easier..

davo10

Fishorsealant wrote: »

Does reducing the distal aspect of upper 6s and 7s get any easier..

Crown prep? Get some short crown prep diamonds. Everything gets easier the more times you do it, except molar endos, those ****ers never get easier.

Fishorsealant

Yes crown preps.
I use the very thin diamond to break the contact but then I swap to normal diamond crown bur and sometimes over reduce the distopalatal margin. Just need more experience with them.
Usually fine for crown preps but trying to get both bridge preps done in time can be tricky at the moment.

btkm8unsl0w5r4

Fishorsealant wrote: »

Does reducing the distal aspect of upper 6s and 7s get any easier..

You have to pick a line and go for it, practice makes perfect.

patem2ar

speed increasing handpiece, two handed prep, good magnification and illumination, ALSO do your occlusal reduction first , it lets you see more of the distal and remember to move the patient not yourself to get as much direct vision as possible.

Fishorsealant

Would you use a canine with 50% bone loss and perio pocketing as a RBB abutment for a 32 ? Opposed by F/

Or double wing 31 and 33 and use as splint as abutments g1 mobile.

Patient accepts SDA but left with extracted 32. Implant not an option. Wants tooth replaced.

Could stabilise perio before restoration.

patem2ar

yes but leave the pontic out of occlusion

davo10

And make sure you clearly outline the limitations of the treatment to the patient giving the worse case scenario, potential loss of both teeth. If this was me, I'd package it as a way of avoiding a denture for a while longer, but not indefinitely.

Fishorsealant

Looking for some opinions on this case.
Patient in 30s.
26,36,46 xla, unrestorable.
All other teeth good.
7s and 5s unrestored.
Can't afford implants.
Wants teeth replaced after I extract them.

Is there any ideal option in this case?
No chance of conventional with virgin abutments.
Not going to RBB a 6 off a 7 or 5.

davo10

What options do you think this patient has and how are you going to do the extractions?

Dianthus

Sometimes leaving a gap (in the short-medium term) is the best option.
Always think - what would I do in this case if this person was my own brother or sister? Makes your decision process& stance a lot easier.
Patient wants& desires are relevant of course but ultimately you know what the most predictable & successful option is, & consider whatever allows you sleep at night.