Harvard School of Dental Medicine Student-to-Student Guide to Clinic: How to Excel in Third Year 2010-2011 Edition Adam Donnell Mindy Gil Brandon Grunes Sharon Jin Aram Kim Michelle Mian Tracy Pogal-Sussman Kim Whippy 1999 – Blaine Langberg & Justine Tompkins 2000 – Blaine Langberg & Justine Tompkins 2001 – Blaine Langberg & Justine Tompkins 2002 – Mark Abel & David Halmos 2003 – Ketan Amin 2004 – Rishita Saraiya & Vanessa Yu 2005 – Prathima Prasanna & Amy Crystal 2006 – Seenu Susarla & Brooke Blicher 2007 – Deepak Gupta & Daniel Cassarella 2008 – Bryan Limmer & Josh Kristiansen 2009 – Byran Limmer & Josh Kristiansen 2010 – Adam Donnell, Tracy Pogal-Sussman, Kim Whippy, Mindy Gil, Sharon Jin, Brandon Grunes, Aram Kim, Michelle Mian 1 2 Foreword Dear Class of 2012, We present the 12th edition of this guide to you to assist your transition from the medical school to the HSDM clinic. You have accomplished an enormous amount thus far, but the transformation to come is beyond expectation. Third year is challenging, but fun; you‘ll look back a year from now with amazement at the material you‘ve learned, the skills you‘ve acquired, and the new language that gradually becomes second nature. To ease this process, we would like to share with you the material in this guide, starting with lessons from our own experience. Course material is the bedrock of third year. Without knowing and fully understanding prevention, disease control, and the basics of dentistry, even the most technically skilled dental student can not provide patients with successful treatment. Be on time to lectures, don‘t be afraid to ask questions, and take some time to review your notes in the evening. Treat every course as an opportunity to learn regardless of the dental specialty that most interests you. Think of yourself as a general dentist in training during these foundational third year courses. There will be time to learn your specialty in the future. Clinic is extremely rewarding. Expect to feel a strong sense of accomplishment as your cases progress. Please remember, however, that everyone has stood in your shoes, so when you‘re challenged by a procedure or feel overwhelmed by the management of a case, know that you‘re not alone. Excellent organization is crucial to your success in clinic. Schedule your patients and procedures well in advance, and call your patients to confirm their appointments (don‘t rely on axiUm). Despite your best efforts, you will have last-minute cancellations and patients who fail to show for their scheduled appointment. Rather than using it as an excuse to sleep in, make the most of your time by assisting your fellow classmates or residents in clinic. You will learn from their techniques. When you are formulating treatment plans, consult with the residents and faculty members from each specialty. The intra-oral photos and study casts that you bring to treatment planning appointments with the faculty are also excellent patient education tools. Your patients will have more confidence in you as a provider, and are more likely to accept treatment. Aside from forming good habits, this will help you maximize your productivity and education. Finally, please remember to maintain a high level of professionalism. Respect the full-time and part-time faculty, assistants, administration, staff, your classmates, and patients. The habits you form now will stay with you for your career. We are all very fortunate to be students at Harvard School of Dental Medicine-- learning from the current and future leaders of the profession. Keep this perspective in mind when you are confronted with day-to-day challenges and frustrations. We wish you the very best of luck during the year to come. Use this guide to its fullest, and know that the fourth years are resources for anything on or off the floor. Sincerely, Adam Donnell, Tracy Pogal-Sussman, Kim Whippy Class of 2011 Acknowledgements We would like to acknowledge and thank all those who have contributed to and supported the ―Student-to-Student Guide to Clinic‖ this year and over the past 11 years. This guide would not have been possible without the teaching and guidance of the Harvard School of Dental Medicine Faculty and Staff. In particular, we would like to thank the following individuals for their contributions through lectures, conversations, and feedback: Dr. Brian Chang, Dr. Isabelle Chase, Dr. John DaSilva, Dr. Bruce Donoff, Joyce Douglas, Dr. Thomas Flynn, Dr. Bernard Friedland, Katherine Hennessy, Dr. Howard Howell, Dr. Anna Jotkowitz, Dr. Nadeem Karimbux, Dr. David Kim, Dr. Sam Koo, Dr. Mark Lerman, Dr. Chin-Yu Lin, Dr. Jarshen Lin, Dr. Maritza Morell, Dr. Shigemi Nagai, Dr. Linda Nelson, Dr. Hiroe Ohyama, Dr. Sang Park, Dr. Nachum Samet, Dr. Jeffry Shaefer, Dr. Peggy Timothé, Dr. Hans-Peter Weber, Dr. Robert White, Dr. Robert Wright, Dr. Bertina Yuen, Dr. Romesh Nalliah, Dr. Dolrudee Jumlongras, Mohamed Alaeddin, Dr. Elsbeth Kalenderian. 3 4 Table of Contents Embryology and Development of Orofacial Structures………………………………………………….…10 Basic Embryology Timeline of Orofacial Development Branchial Arches Face, Tongue, Thyroid Development Tooth Development Tooth Histology Dental Anatomy…………………………………………………...…………………………………………..16 Anatomic Trends Anatomy of Permanent Dentition Anatomy of Primary Dentition Occlusion Rules Head and Neck Anatomy………………………………………………………………………………….….28 Cranial Nerves Foramina of the Cranium Nerves and Receptors Muscles of Mastication Salivary Glands Clinic Operation…………………………………………………………………………………….……..….31 Attire Patient Flow Treatment Planning and Treatment Plans ADA Codes Charts / Charting Patient Management Sterile Technique Emergency Management Common Medical Emergencies New Patient Basics…………………………………………………………...………………………………..37 Operatory Set-Up History and Exam Alginate Impressions Using the Rubber Dam Medical Risk Assessment………………………………………………………………..…………………....39 Stress Reduction Protocol Medical Conditions and Necessary Precautions ASA Classification Antibiotic Prophylaxis Guidelines…………………………………………………………………......…….41 Pharmacology……………………………………………………………………………………... ……….....42 Drug Metabolism How to Write a Prescription Oral Pain Antibiotic Prophylaxis Bacterial Odontogenic Infections Periodontal Diseases Fungal Infections Ulcerative/ Erosive Conditions Anxiety/ Sedation 5 High Caries Drug Interactions Antibiotics Overview Dental Instruments………………………………………………………………………………………..…..47 Dental Materials……………………………………………………………………………….………...…………….50 General Concepts Material Properties Overview of Dental Materials Materials We Have In Clinic Oral Care Products……………………………………………………………………………….. ……...…..59 Toothpaste Mouth rinse Overview of Selected Brand/Products Calculating Fluoride Concentration Local Anesthesia…………………………………………………………………………………….............………..62 Vasoconstrictors Anesthetics Mechanism of Action Specific Anesthetic Dosing Sample Anesthetic Calculations Techniques for Local Anesthesia Periodontics……………………………………………………………………………..……………………..66 Treatment Scheme and Goals Periodontal Definitions Risk Factors for Diseases of the Periodontium Dental Plaque Formation Microbiology of Periodontal Disease Periodontal Exam Radiographs for Periodontics Etiology of Recession Role of Occlusion in Periodontal Health Periodontal Diagnosis: ADA and AAP Non-Surgical Periodontal Procedures Periodontal Instruments Antibiotics in Periodontics Periodontitis and Systemic/Environmental Links Set-Up for Periodontal Surgeries Surgical Periodontal Procedures Grafting Socket Preservation Sutures Follow-Up for Periodontal Surgeries Wound Healing Operative…………………………………………………………………………………………..…………..77 Caries: Etiology Caries: Progression / Diagnosis Caries: Treatment / Prevention Caries: Classification G.V. Black Principles Pulpal Protection 6 Direct Restorative Materials Overview of Bonding Temporary Restorative Materials Evaluation of Existing Restorations Operative Procedures Endodontics……………………………………………………………………..………………………..……84 Emergency Exam Pulpal Diagnosis Periapical Diagnosis Dental-Pulp Complex Cracked / Fractured Teeth Root Resorption Vital Pulp Therapy vs. Non-Vital Pulp Therapy Emergency Therapy Endodontic-Periodontic Combined Lesions Access Opening Cleaning and Shaping Obturation Endodontic Procedures Prosthodontics…………………………………………………………………………………….. ..…….…..96 General Concepts Materials in Prosthodontics Mandibular Movements and Occlusion Crowns and Fixed Partial Dentures………………………………………………………………………..……100 Indirect Restorations Single Crown Preparation Multiple Unit Preparation Veneer Preparation Color Science Clinical Procedures and Lab Processing Post and Core………………………………………………………………………………………….………...107 Overview of Cores Overview of Posts When to Use a Post and Core Post and Core Failures Post and Core Procedures Complete Dentures…………………………….………………………………………………..………………111 General Concepts Evaluation of the Edentulous Patient Vertical Dimension of Occlusion Speaking Sounds Denture Occlusion Schemes Steps in Complete Denture Fabrication Lab Remount Clinic Remount Immediate Complete Dentures Steps in Immediate Complete Denture Fabrication Repair and Maintenance Overdentures Removable Partial Dentures………………………………………………………………………...............…..118 General Concepts RPD Components Steps in RPD Fabrication 7 Steps in RPD Fabrication – Altered Cast Technique Immediate RPD Fabrication Implants………………………………………………………………………………………………………123 Background Indications/ Contraindications Seibert Classification Implant Sequencing Protocols Implant Options Space Requirements Referring a Patient for