1

Family Dentistry Clinical Protocols 2016-2017

General

1. The instructor who verifies comprehensive examination findings must “sign” (approve in AxiUm) the treatment plan before you can begin any restorative care. All proposed treatment (including from recall exams) must be entered in the treatment plan module. With complex cases, if the treatment plan is not finalized, limited treatment can be performed only if the instructor makes a specific notation on the Treatment Plan/findings sheet.

2. Except for excused absences, you are expected to be on the clinic floor and/or available to handle emergencies. If you are not in your clinic operatory, you must let your instructor know where you are and leave a note on your clinic chair indicating where you can be reached. If you have no scheduled patient or a patient fails, immediately contact the clinic clerks to be placed on the emergency call list. If you have no patient or when appointments are finished early, you can also practice on manikins for boards examinations while you wait to be assigned emergencies.

3. You are responsible to review your patient’s medical, clinical and radiographic history prior to the appointment and be familiar with previous treatment as well as the patient’s current status. You are expected to present this information in a professional way to the faculty and provide a summary or overview of the patient’s status and chief complaint during the initial check. We recommend you use the following outline for start checks:

START CHECKS

-Introduce patient -Medical hx (summary) -Medications / allergies -Blood pressure -Chief complaint -Radiographs (needed?) -Caries risk assessment (if time allows while waiting) - Modifiers (ie: DWP, XIX, travel time) -Your plan for the appt. -If recall, ask faculty if they want to check the exam before the prophy

4. Rubber dams must be used for restorative treatment. This includes post preparations. Your instructor must give you permission if an exception is to be made.

5. AxiUm notes, codes, and any FAMD required paperwork must be completed before your faculty gives you the final check for each patient. Keep in mind that adjunct faculty may not be back for a week (or more) to swipe or sign incomplete items.

6. DO NOT forge instructor signatures on any paperwork. Those who do will be referred to the Collegiate Academic Professional Performance Committee for disciplinary action.

2

7. Out of courtesy, if you intend to call in a consult or work with another instructor on a specific procedure, please advise the instructor on the floor of your intention at the start of each clinic session.

8. A diode laser is available in the dispensary. Before using, read the College of Dentistry Laser Safety Manual and take the Laser Safety Course on Intradent / Faculty / Laser Safety Training. Submit your quiz to Cheryl in the FAMD office. The laser screen is stored in S306. Supervising faculty must be laser certified. The list is posted on the main bulletin board. Use the laser template for charting. Return the laser storage tub exactly as you found it.

If using the laser as an adjunct to a procedure, when electrosurgery or retraction cord are also options, use code D4999 (unspecificed periodontal procedure) and charge $5.00 to cover the cost of the disposable tip. There will be 0 RVUs awarded. If, on the other hand, tissue MUST be removed to enable the restorative procedure, use code D4212 (gingivectomy or gingivoplasty to allow access for restoration). Be sure to treatment plan the procedure and advise the patient of the fee ($90). This procedure is worth 3 RVUs. Contouring of hyperplastic gingiva with the laser would be coded D4211 (gingivectomy/plasty 1-3 teeth) with a fee of $110 and 6 RVUs. This would not be in conjunction with a restorative procedure.

9. All patients requiring antibiotic premedication are to be pre-rinsed with chlorhexidine gluconate .12% (10 ml 30 second swish and expectorate). This must be charted as a prescription. This protocol will be one of the dosage selections under chlorhexidine. There is no wait time. The procedure can begin immediately. The chlorhexidine is located at the ends of both teaching stations. If alcohol use is contraindicated (for example: religious belief, Antabuse, recovered alcoholics), go to the pharmacy to receive 10ml of alcohol free chlorhexidine.

U. of Iowa COD SDF Protocol

1. Obtain verbal consent for the application of SDF that covers the following items: Expected change in color (decay will turn black), likelihood of reapplication, need for future treatment, and possible temporary discoloration to the gums and cheeks in case of accidental exposure. 2. Make sure you use a metal pan to contain all supplies used during silver application. 3. Standard Personal Protective Equipment (PPE) for provider and patient, extra plastic lined cover (patient bib) for counter tops. 4. You will receive one drop of SDF in a dappen dish from the dispensary. 5. Isolate affected teeth with cotton rolls / dry angle and saliva ejector. 6. THOROUGHLY dry affected tooth surfaces with triple syringe. 7. Bend microbrush, immerse into SDF, remove excess on side of dappen dish. One drop can treat 5-8 lesions. 3

8. Apply directly onto the affected tooth surface(s) with microbrush . Application time: 1-3 minutes. 9. For interproximal lesions, apply to buccal or lingual with microbrush. The SDF will wick. 10. Apply Fluoride varnish on the treated area with BendaBrush. If you apply varnish to the rest of the teeth, use ANOTHER BendaBrush. 11. Invert any supplies that have encountered SDF into your gloves during removal. Then deposit directly into garbage container. 12. In case of possible touching or contamination of the lips or face with silver, use a saturated solution of salt on a 2”X2” gauze to wipe the area. 13. Please watch the videos available at this link for application of the agents prior to your application: https://www.youtube.com/watch?v=Hpv43jvNn9s 14. Use code D1354 Interim Caries Arresting Medication ($35) whether you treat one or more teeth. This code gets billed out only once per visit, irregardless of the number of lesions treated. 15. Remember, SDF will permanently stain almost all surfaces BLACK.

Prosthodontics (4/2015)

A. Diagnostic Casts 1. Diagnostically articulated casts are considered part of the diagnosis and treatment plan. They MUST be completed on all patients requiring removable partial dentures, two or more fixed units, or combination cases where both fixed and removable partial dentures are planned. Mounted diagnostic casts must include an occlusal analysis (yellow form) before any restorative work is started. Occlusal vertical dimension, space for restorative material, and occlusal plane acceptability will all be evaluated during occlusal analysis. 2. If there is a change in the oral condition as a result of the treatment completed during the disease control phase (such as the loss of one or more key teeth), the diagnostic casts will likely need to be remade.

B. Removable Prosthodontics 1. The prosthodontics gold sheet with a removable RPD design is part of the patient’s diagnosis and treatment plan. This must be completed for all RPD patients PRIOR to any restorative treatment (not while the patient is in the chair). When changes occur with key teeth during the disease control process, any fixed or removable treatment plan must be re-evaluated (again, not while the patient is in the chair). 2. RPD master casts being sent to a laboratory for framework fabrication MUST be articulated when opposed by natural teeth or another RPD. 4

3. All RPD work authorizations must be accompanied by two casts. One is the tripoded and articulated master cast, the second on which the design has been drawn. This will require two separate impressions (of which one may be a good alginate). 4. All complete denture cases will be articulated with a facebow transfer on a Hanau, semi-adjustable articulator. 5. Continuity of faculty supervision is important in all complex prosthodontic cases, and especially for complete denture cases. It is highly recommended that students schedule all appointments for a complete denture patient under the supervision of the same faculty member. Department of Family Dentistry policy states that MEE credit will NOT be awarded if there are more than two faculty signatures from preliminary impressions through final denture insertion. “Dentures by committee” ARE NOT ALLOWED. 6. Deviations from protocol MUST stay with the same instructor to completion and follow- up. 7. MEE Complete Denture credit will not be awarded if the complete dentures, upon delivery, are not clinically acceptable or QA form not filled out and turned in. C. Fixed Prosthodontics 1. Determine restoration type before starting prep. 2. Indications/ Contraindications for All-Ceramic Crowns: 1) Conventional single units only (no FPD or RPD abutments) unless cleared through Group Leader 2) Adequate occlusal-gingival height of unprepared tooth (at least 6 mm). 3) Stable occlusion: a. Posterior restorations: One should be able to achieve minimal excursive contacts on the all-ceramic restoration; especially against natural teeth. There should be anterior/canine guidance or progressive group function present. b. Anterior restorations: Finished all-ceramic restoration should be in harmony with existing anterior guidance. Avoid exclusive guidance on all-ceramic restoration (harmonize the guidance with natural teeth) c. Patient should not have parafunctional habits (presence of multiple wear facets)

4) All-ceramic restorations are not indicated where a feather edge margin may have to be used. (Examples; deep foundations, pins present in foundation, fractured teeth etc.). 5) Anteriors with deep vertical overlap and centric contacts near the gingiva usually do not provide adequate clearance and are contraindicated. 6) Patients who have multiple teeth with a questionable prognosis or have an existing RPD may not be appropriate candidates for all ceramic crowns. 7) Not appropriate for second molars or RPD abutments (unless retrofitting to an existing RPD and CAD/CAM can be used—see your instructor).

3. General Fixed Protocols

1) Any individual crown to be fabricated as a surveyed crown must have an approved RPD design/gold sheet prior to appointment. 5

Custom trays are required for fixed cases and should cover all edentulous areas including the tuberosity, retromolar pads, plus the palate. This will allow for base plates, if needed. Record bases are required if the cast articulation is not stable. 2) Mandibular record bases should have adequate extension for stability and utilize (2) thicknesses of light cure material to reduce flexibility. Prefabricated lingual connecting bars are available. See Ken in the lab. 3) There should be no cross arch impressions. 4) Poor impressions can not be relined to save the day. Any transfer die impressions must capture 360° of the margin in the impression. 5) For new crowns under existing RPD’s: ideally an indirect resin coping should be fabricated on the die and clinically bead brush all RPD surfaces contacting the surface of the proposed crown. The RPD must be stable and well fitting; make note of the RPD’s framework contact with all tooth surfaces. Crowns will not be made for ill-fitting RPDs. Alternatively, the RPD may be picked up in the PVS final impression. The tray needs to be made on a cast with RPD in place. The exception is for crowns where no part of the RPD is contacting the proposed crown. Your instructor may also suggest a CAD/CAM procedure. 6) On cases where the most distal tooth is a bridge abutment a rigid material (resin or rigid PVS) should be made to accurately articulate the case. 7) Impressions are sent to commercial labs for pouring and pindexing. You will articulate the case. Do not apply die spacer as lab will provide. All FPD’s must be articulated on an adjustable articulator. 8) All FPD’s and/or anterior crowns involving three units or more must include settings for the mechanical anterior guide table or a custom incisor guide table. Include a cast of esthetically acceptable provisionals. All FPD’s with more than 2 pontics must be approved by your group leader. All FPD’s must have framework try in. 9) Copious air-water spray should be utilized while making occlusal adjustments and polishing of all-ceramic restorations. A special porcelain adjustment kit for all porcelain restorations is available in the dispensary. All ceramic restorations must be polished to a very high shine. 10) Refer to the ceramic crown luting flow chart for cement selection and intaglio management instructions.

D. Triple Tray Impressions 1. A “triple tray” impression technique can be used for a single posterior tooth with adjacent teeth present. It cannot be used for anterior crowns, multiple units, crowns on the most distal tooth in the arch, or where a surveyed crown is indicated, even if the patient does not presently intend to receive a removable partial denture. Also the triple tray should not be used where a large curve of Spee is present or where the crown is opposed by a complete denture or an RPD. A triple tray can not be used to “pick up” an RPD. 2. A triple tray impression can be used for fabrication of indirect cast post and cores. Make 2 impressions if time allows.

6

PERIODONTICS (4/2015)

1. DO perform a comprehensive periodontal exam on all NEW patients to the FAMD clinic. DO fill out the first 6 tabs of the Perio Assessment Form similar to your D3 perio rotation, but ONLY for moderate to severe chronic perio patients.

2. For perio maintenance patients being transferred to you, DO check to see if there has been a full perio charting done in the last 12 months. If not, DO one. You must read back in the chart to determine this.

3. DO evaluate each patient in your chair for either a mock board scale or the real thing! DON’T wait until boards gets close to start looking for patients!

4. DO keep a Periodontal Case Record (the pink sheet) for each Scaling & Root Planing (SRP) patient. . It must include the patient’s information and their periodontal diagnosis. It is the ONLY record of RVUs awarded for SRP and must be retained by the student.

5. DO feel free to work on caries control during SRP. Scaling and Root Planing is part of disease control and can be part of “Quadrant dentistry.”

6. DON’T proceed with the reconstructive phase, until the periodontist assigned to Family Dentistry for that day has reviewed the case with you. You must fill out the last 2 tabs of the Perio Assessment Form. The periodontist will approve both the form and the D0120.3 code (periodontal re-evaluation). This does not imply that all probing depths need to be eliminated, but it DOES mean you must have a plan to treat the residual periodontal defects. You will note this on the Periodontal Case Record listed above as well as in your EHR note and treatment plan ALL PERIO patients should be on some type of perio maintenance, whether they are scheduled for surgery or not.

7. DO attempt to assist or at least observe periodontal surgeries that you refer to the Periodontal clinic. It’s a great way to follow along with your patient’s treatment and see how residual defects can be treated.

7

ENDODONTICS in FAMD (5/29/2015)

Don’t

The following conditions will not be treated in the Family Dentistry Clinic:

a) Patients who on radiographic assessment have significant curved roots, unusual root anatomy and morphology, calcified canals or pulp chambers located below the cemento- enamel junction (CEJ). b) Patients who require root canal treatment through full coverage restorations. c) Patients who require retreatment of a tooth that has had previous root canal treatment. d) Upper second molars with limited access and or fused roots. e) Patients with internal/external resorptive defects. f) Patients who require surgical intervention, including incision for drainage. g) Case should be evaluated using the Endodontic Case Difficulty Assessment Form. If the total of points is above 20 points, the case should be referred to an endodontic resident or faculty member. It might be treated in FAMD with faculty permission and supervision.

Conditions b, c or g might be treated in FAMD if the case is assessed and approved by an endo faculty prior to the initiation of the treatment.

Don’t schedule patients for endodontic procedures on Monday mornings or Wednesday afternoons because there is no coverage in FAMD by a faculty member of the Department of Endodontics.

Cases not treated in FAMD will be referred to Endodontics.

ENDODONTIC TREATMENT

a) Students who have scheduled a patient for an endodontic procedure must sign up in advance on the sign-up endo sheet posted on the consultation board.

b) Prior to the initiation of an endodontic case, the endodontic diagnosis/treatment form for each case should be filled out.

c) Each case should be evaluated for the degree of difficulty as outlined on the Endodontic Case Difficulty Assessment Form. If the total of points is above 20, the case must be referred to Endodontics.

d) Each case must be initiated and completed by the same student.

e) Once the case is selected and diagnosis and treatment plan has been established, a faculty signature is necessary on the front of the first page (second column) PRIOR to the initiation of treatment. 8

f) The endodontic consent form must be reviewed signed by the patient PRIOR to the initiation of the treatment.

g) Individual procedural checks are outlined on the reverse side of the endo sheet and faculty signatures MUST be recorded for each step in the acceptable/ unacceptable areas. It is the student’s responsibility to insure each procedural step is signed by the faculty.

h) Following completion of treatment the section Obturation Evaluation on the front page (second column) must be completed and signed by the faculty.

i) Preoperative and postoperative radiographs must be taken with the XCP paralleling device and saved in the patient’s record.

j) Upon completion of treatment the proposed recall date should be entered on the patient’s electronic record and the completed endodontic sheet for ALL cases should be turned to Cheryl Jennings in Room S-313, Family Dentistry office.

If for a special situation (emergency condition, patient’s schedule, and or transportation limitations) the patient has to be seen in one of those days, he or she must be treated in the junior clinic under endo faculty supervision. To do that, the student has to speak with me first and then I’ll check with Ruby the operatory availability in the endo junior clinic for that specific day.

If you have any question or concern please contact me or e-mail me at: [email protected]

Manuel R. Gomez, DDS Clinical Associate Professor Coordinator of Endodontics in Family Dentistry

9

OPERATIVE DENTISTRY (4/2015)

The guidelines for the operative dentistry procedures in the Department of Family Dentistry follow the criteria and philosophy of the guidelines taught from the Operative Dentistry Department from freshman to junior year. For a detailed description of all the operative procedures and guidelines please refer to the Operative Dentistry Best Practices link: https://www.dentistry.uiowa.edu/operative-best-practices

Cariology and Minimal Invasive Dentistry

1. Assessing caries risk status of every dentate patient is essential and must be performed before a treatment plan can be determined. Since the caries risk status and management is cyclical, the patient should be placed in a risk based recall interval (6 mo for moderate to low patients and may be more frequent for high caries risk patients. (3-4 mos recall is suggested).

2. After Assessing caries risk of the patient, a caries risk factors management plan should be performed (clinical recommendations for the patient) with the aim to lower the risk status of the patient (moderate or high) and to maintain if low. The risk assessment drives the decision about preventive, therapeutic, behavioral and restorative approaches and determines which of the risk factors involved needs modification to correct the imbalance between protective and destructive factors and prevent future caries lesions formation.

3. The clinical management of non-cavitated caries lesion can vary from a low to a moderate and high caries risk patient. Assessment of caries risk is necessary to determine the surgical or non-surgical treatment of the lesion(s)

4. Dental caries diagnosis must be completed with adequate light and magnification. The teeth must be thoroughly dry and clean (Biofilm must be removed in plaque stagnation areas). An explorer should only be used as an adjunct to determine texture.

5. Do remineralize and seal non cavitated pit and fissure lesions according to the individual caries risk assessment.

6. Do remineralize smooth surface non cavitated lesions (white or brown) according to the individual caries risk assessment. This can be applied (based on clinician judgment) when a large demineralized area is adjacent to the margin of a restoration and its removal will involve excessive loss of tooth structure that can otherwise be treated by remineralization techniques.

10

7. Defect specific preparations & appropriate material selection will preserve tooth structure. Minimal invasive restorative options, if needed, should be based on the location (site), depth (severity) and activity of the lesion, as well as, caries risk status

8. In cases of deep caries lesions conservative caries removal techniques such as Indirect Pulp Treatment (IPT) or Stepwise excavation (SWE) should be considered to protect and maintain pulp vitality following the biological knowledge and considerations but without compromising the integrity of the restoration.

9. When using any conservative or partial caries removal technique, the case selection, tooth restorability, insurance coverage and a detailed preliminary assessment are crucial. A pulpal\periapical evaluation including pulp test (EPT CO2), PA radiographs, signs and symptoms and preliminary planning of the procedure are critical steps to achieve success as well as long-term evaluation and follow-up. These steps must be performed and discussed with the faculty and the patient prior performing the procedure. Refer to the FAMD document Guidelines for Incomplete Caries Removal in Deep Caries Lesions for specific guidelines.

ESTHETICS

1. If improved esthetics is a patient concern and is a goal in your comprehensive treatment plan, please be sure that you perform the appropriate steps for diagnosis and Tx planning such: • Esthetic analysis • Mounting , Diagnostic wax-up • Diagnostic esthetic mock up • Photographs 2. Bleaching options should be discussed with the patient prior to any procedures in the esthetic zone. 3. You may need to do a consult with one or more faculty depending the complexity of the case and disciplines involved. 4. Try to work with the same faculty or group of faculty that are familiar and feel comfortable supervising the case.

Guidelines for Bleaching (adapted from Operative Dentistry)

Over the past two decades, tooth whitening has become one of the most popular esthetic treatments and is defined as a treatment involving an oxidative chemical, that alters the light absorbing and/or light reflecting nature of a material, thereby increasing its value. In general, most dentist-prescribed at-home and in-office whitening techniques have been shown to be effective. However, results may vary depending on type of stain, age of patient, concentrations of the active agent, and treatment time and frequency.

11

Precautions Avoid whitening if pregnant and avoid smoking, coffee, tea, staining foods/beverages. Restorations don’t whiten. Inform patient of replacement needs and additional costs Wait 2 weeks after whitening before restoring to enable color stability and bond strength recovery

Tooth Sensitivity Sensitivity commonly presents itself as generalized sensitivity to cold stimuli, but often also occurs as a spontaneous sharp shooting pain or “zinger” limited to one or few teeth. Recommend reduce tx time or increased tx interval for patients with mild sensitivity. UltraEZ/Relief ACP/Prevident 5000 Sensitive for moderate to severe sensitivity. Options for moderate to severe sensitivity include Ultra EZ, Relief ACP, and Prevident 5000 Sensitive.

Type of Whitening Treatment The type of whitening performed depends mainly on patient’s preference and severity/type of tooth discoloration. At-home whitening is recommended for patients with good compliance, whereas in-office whitening is suggested for patients desiring faster results without the need to wear trays. The efficacy of light activation for in-office whitening is still controversial and we leave the decision for use to the practicing clinician.

Appointment Sequence for At-Home Whitening (D9975) Initial examination visit: Diagnosis, consultation, shade taking, photos, impressions Delivery visit: Try-in trays. Dispense 6 tubes of Opalescence 10% per arch, tray storage container and niteguard home bleaching instructions. Monitor every 2 wks. Depending on severity and patient compliance, whitening may take 2-6 weeks. Tetracycline stains may need an extended period for up to 6 months.

Pre-doctoral nightguard vital bleaching fees

D9975 Clinic patients $130/arch (includes bleaching agent) Family members, staff, and dental students $50/ dental arch

D9975.1 Touch-up (4 tubes of bleaching agent) $26 (for ALL fee classes)

****IMPORTANT: EVERY STUDENT OR STUDENT FAMILY MEMBER CASE MUST BE ENTERED AS A PATIENT OF RECORD. A DIAGNOSIS, DELIVERY AND FOLLOW UP APPOINTMENTS NEED TO BE COMPLETED AND PROCEDURE CODES AND NOTES MUST BE ENTERED AND APPROVED BY A FACULTY MEMBER. MATERIAL WILL NOT BE GIVEN IN THE DISPENSARY UNLESS A WALK OUT STATEMENT IS APPROVED BY A FACULTY MEMBER.

12

Adhesively cementing ceramic restorations – Bonding Scotchbond Universal and Multilink Automix. (Feldsphatic – Empress – E.Max) Marcos A Vargas - Department of Family Dentistry

Before beginning or as soon as restorations are received from lab find… 1. What ceramic is it? Lava Ultimate (3M-ESPE) Chairside 2. What did the lab did to the intaglio surface? CD/CAM restorations (Cerec – E4D). a. Etching, what etching? How long? Sandblast intaglio surface. b. Silane treatment? Yes or no? Not susceptible to HF etching

Clinical procedure 1. Try restoration – restorations, one at a time. Restoration and tooth should be dry. (Water will mask the fit of the restoration). If Necessary, adjust ceramic with copious amount of water and a fine diamond. BE GENTLE. USE RUBBER DAM!!!

2. If multiple restorations, try all restorations at the same time to evaluate overall fit.

3. Placed a drop of water in each restoration and show patient for approval. (Instruct patient that restorations are not cemented and avoid swallowing or chewing if they feel something foreign in their mouth).

4. If ceramic has not being prepared (etched and silanated) then proceed according to type of ceramic:

a. Feldsphatic - Etched intaglio surface with

Porcelain etchant (9.5% HF) for 60 sec. b. Empress or leucite reinforced - Etched with intaglio with

Porcelain etchant (9.5% HF) for 20 sec. c. E.max or Lithium disilicate reinforced – Etched intaglio with 13

Porcelain etchant (9.5% HF) for 10sec. 5. Rinse and dry

6. If ceramic has been prepared (etched) and silanated

a. Ultrasound clean in ETOH for 2min

7. If ceramic has been etched and not silanated. Mix the BIS-SILANE by dispensing one drop from each of the two bottles (Parts A & B) into a mixing well and stirring. Brush on 1-2 coats (thin coats are sufficient) of BIS- SILANE to the internal surface of the etched porcelain restoration and wait for 30 seconds. Dry with air syringe.

8. Dispense a drop of Scotchbond Universal adhesive onto a dappen dish and apply to intaglio surface.

9. Dry thoroughly (BE AGGRESSIVE) and light cure for 10 sec. Do not let adhesive pool – It will affect the fit.

10. Place restorations in tray sequentially and in the sequence they are going to be seated.

11. Etch the preparation using conventional etch for enamel and dentin (37%H3PO4). Apply to enamel first then to dentin. Rinse thoroughly. Remove excess water using a cotton pellet, leaving the preparation moist.

12. Dispense a drop of Scotchbond Universal adhesive onto a dappen dish and apply to preparation, agitate over tooth surface for 10 sec applying 2-3coats.

13. Thoroughly air dry (BE AGGRESSIVE) until there is no visible movement of the material. The surface should appear shiny; otherwise, apply additional coats of Scotchbond Universal and repeat Step 12. 14

14. Light cure each surface for 10sec. at 500mW/cm2.

15. Apply Multilink Automix to the internal surface of the restoration directly from the mixing syring. Or apply to cavity preparation (inlays).

16. Seat each restoration with gentle, passive pressure.

17. Remove excess cement immediately with a brush or instrument. Make sure the restoration is completely seated.

18. Light cure each surface of the restoration for 40 seconds. [Tack light curing is possible by light curing for 3sec. each surface then remove excess cement]

19. Check occlusion.

20. Clean up excess and polish margins if necessary with resin composites polishers. Porcelain should be adjusted and polish w ceramic polishers.

GOOD LUCK! BE READY IN ADVANCE