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THE NEXTDDS Student Ambassador Blogs

Patient Management: Sevens Steps for Success

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 My goal for this spring semester has been to concentrate my appoinntments on patient comfort.  I have set strcit guidelines and steps that I would like to master for each and every appointment.  It has been a very rewarding process and one that I will implement into my daily appointments, further beyond this semester.  Following is a list of steps that I would try to accomplish during each appointment.  Following each step, I have provided how I accomplished these, as well as successes and failures. 

1. When greeting patient, offer to carry coat, purse, or other items back to operatory and place them off the floor.

Prior to each appointment, I would stop at my locker and read a note that was placed on the inside door, in order to put myself in the appropriate mindset before getting my patient.  This note was very important to read on days that I was rushed or stressed to get to the next appointment.  At times, I didn't feel it was necessary to make that extra stop at my locker, but I continued to force myself to stop because I understood the importance of reframing my mind.


2. After seating patient, do a head to toe check for patient’s comfort, including checking headrest position and offering a pillow for neck/back support.

For all fifteen appointments, I would check out a neck pillow, even before I knew if the patient wanted it or not.  I wanted to be prepared, not waste time by going back to dispensing, but also serve as a reminder, by having the pillow on the counter, to ask the patient if they prefer the pillow or not. Also, I would make sure the instrument tray did not interfere with the patient's feet upon seating him/her.  Checking the headrest became the most important step for me because prior to this time period, I would not confirm the headrest was in the proper position.  More times than not, the headrest needed significant adjustments, a fact that I missed quite often before.


3. Offer patient Vaseline or other lip moisturizer at the start of the appointment and then a second time after two hours in appointments lasting two hours or more.  

While setting up my cubicle, I would consistently place Vaseline in a yellow container, and topical anesthetic in a red container.  I would do this because once each were out of their original containers and on Q-tips, it was nearly impossible to tell the difference.  After repetition of using the same colors, I was able to gain a routine.  Having the Vaseline at my cubicle prior to even getting the patient cued me to offer this to me patient.  However, I found it difficult to remember to offer the patient Vaseline after two hours into the appointment, but when offered after two hours, I noticed that most patients refused it anyway.


4. Negotiate with the patient a sign to communicate if any discomfort is occurring.  The sign will be to raise the left hand.

Raising the left hand during any times of discomfort was an ideal non-verbal communication. This is because they would not accidentally hit my right hand, and I would also be able to visualize their action better.  I had a few patients that didn't do as well with this step, and it baffles me, but I suppose it is because it is an unusual human behavior to raise a hand, rather than just trying to say something.


5. Ask on average at least once every 30 minutes throughout the appointment about patient comfort, including, where applicable, after injections, rubber dam placement, use of the high speed and slow speed for the first time, taking impressions.

This was the most challenging step.  I realized that thirty minutes goes by very quickly and asking constantly was hard to remember when I was focused on the procedure at hand.  After a different step in the procedure, it was easy to remember because the change of pace offered a cue for me to ask about comfort issues.  However, if the same procedure was done (for example, using the high speed) for a consecutive thirty minutes or longer, it felt monotonous to ask the patient about comfort.  Sometimes, if asking too often, it will put questions in the patient's mind that they should be experiencing discomfort.


6. For appointments lasting more than two hours, offer a bathroom or stretch break once mid-way in the appointment.

At about two hours into the appointments, I, myself, needed a mental and physical break too! This step was easy to implement.  I found that most patients took me up on the offer of a restroom break, which was surprising to me.  Before, I rarely took patients to the restroom, but simply asking, they were more willing to say they did indeed need a break.


7. At the end of appointments, offer patients some mouth wash to refresh their breath before being dismissed, assisting with suction as needed. 

I absolutely loved implementing this step into my appointment routines.  I found a lot of patients really enjoyed having the opportunity to swish with mouthwash prior to leaving.  Actually, I called a few patients in the evening and they thanked me for this and said that no one has ever offered mouth rinse before! I will definitely continue to implement this step from now on in the future.

Crown types and options

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How to decide on what type of crown?


In pre-clinical lab, I learned three types of crown preps: 1) all metal, 2) porcelain fused to metal and 3) all ceramic. We essentially learned that the differences of these crown types had to do with how much tooth structure we needed to reduce (0.5mm, 1.5mm etc) and what type of margin we needed to prepare (chamfer, shoulder, etc).  We never discussed why you would pick one type of crown over another. We certainly never discussed, once you decide on which type of crown, which type of material to use. Now that I am treating patients in clinic and having to write lab prescriptions on a daily basis for crowns and bridges, I have come to realize that this is crucial information that should be understood thoroughly before picking up a hand piece to begin a crown preparation.


All-metal crowns are used mainly in the posterior. The advantages of such a tooth are strength, longevity, less wear on opposing dentition and less tooth reduction is necessary. The only disadvantage of this crown is the un-esthetic metallic appearance.  Once you have decided on an all-metal crown, you must now choose which type of alloy to use: 1) High- noble 2) noble or 3) non-noble. The most preferable choice is the high noble, which is at least 60% noble metal, of which at least 40% must be gold. Because of the content of noble metals, the high noble crown is also the most expensive. The non-noble option is the least expensive, but it also posses an allergy risk to about 15% of the population due to its nickel and chrome content.


Porcelain fused to metal crowns (PFMs) are advantageous because they combine the strength of a metal crown with the esthetic appearance of a porcelain crown. A disadvantage of the PFM is that porcelain can cause excessive wear on the opposing dentition. This is especially important for people with a bruxing habit. Additionally, a greater amount of tooth reduction is required to make room for both the porcelain and the metal.


All-ceramic crowns and the most esthetic crown option because more of the crown is made of translucent materials, like porcelain, that mimic a natural tooth’s coloring.  Another advantage is that all-ceramic crowns cause no more wear on the opposing dentition than actual enamel would cause.  In certain dental offices that have milling units, all-ceramic crowns can be fabricated “same-day in office.” There are machines that can fabricate crowns out of ceramic blocks in less than an hour. A disadvantage to all-ceramic crowns is that they have inferior physical characteristics, such as reduced strength, reduced hardness and reduced resistance to fracture. Fore this reason, all-ceramic crowns are more commonly placed in the anterior.


Once you have chosen an all-ceramic crown for your restoration, you must decide which type of ceramic to go with. There are several main categories: 1) Feldspathic Porcelain 2) Reinforced Glass-based ceramics- IPS Empress 3) Reinforced Glass based ceramics- IPS E.Max, 4) Zirconia based


The Feldspathic is a powder-liquid porcelain. They can be layered and therefore can have multiple opacities. It must be bonded to teeth instead of cemented. Marginal integrity is a disadvantage, as chipping at the margin is common.


IPS Empress porcelain is leucite reinforced, which makes it twice as strong as traditional porcelain. The must be bonded instead of cemented as well. The marginal integrity is superior to Feldspathic because of the method of fabrication. It should not be used with dark preparations because of its high level of translucency.


IPS E.Max is reinforced with lithium disilicate, is twice as strong as IPS Empress and it can be cemented as long as there is 2.0mm thickness of ceramic material. Due to the increased strength, it can be used in short span bridges, but not for molar replacement.


Zirconia- based restorations are very strong, much stronger than the other all-ceramic options, which are glass based. Zirconia can be used as an alternative to metal options because of its strength. It can also be used in posterior bridges that replace molars and long-spanning anterior bridges.


I hope that this brief overview helps new dental students out when thinking about crown types for specific teeth. There is a wealth of information on specific brands, metals, ceramics and designs online. I encourage everyone to do some research before your next crown preparation!



Medical Emergencies: How Ready Are You?

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Medical Emergencies: How Ready Are You? 

As dental students, we have faculty to guide us through the procedures and help us during emergency situations. It is very important to keep in mind that we are not just dentists, but we are medical professionals that treat the oral cavity. We must take a complete health history for every patient and update it every visit, along with monitoring vital signs and maintaining adequate records. Most emergencies can be prevented with adequate preparation of the patient and staff. It is also our responsibility to be knowledgeable about state dental practice acts and the requirements for dealing with emergencies.  

The first step is to learn to recognize signs and symptoms indicating emergency. Dental treatment should be stopped immediately, and an assessment of the patient’s condition should be performed to determine if it is necessary to contact Emergency Medical Services (EMS) or if treatment can continue. If the patient was receiving nitrous oxide, it should be discontinued. 100% oxygen should be given in its place in every case except for hyperventilation. 

Stress is the major factor causing medical emergencies in the dental office. For example, it may be the cause of syncope, hyperventilation, seizures, asthma attacks, and angina. Some helpful ways of reducing stress for patients are reducing waiting time, allowing enough time for the scheduled procedure, thorough explanation to avoid surprises in the operatory, and making sure patients feel comfortable. Also, remember that some patients may need to be premedicated with anti-anxiety agents. Adequate pain control should be used and longer procedures should be divided into shorter dental appointments. 

Syncope, or fainting, is the most commonly reported medical emergency in the dental office. It is caused by cerebral hypoxia and usually preceded by a sensation of light-headedness. Facial pallor is often the first sign of an impending vasovagal faint, and usually followed by yawning, sighing, sweating, restlessness, salivation, and pupillary dilatation. The patient should be placed in a supine position with legs elevated. The universal feature of syncope is that patients recover quickly, being well-coordinated and capable of performing purposeful movements in as little as 20-30 seconds. However, syncope lasting more than a few minutes can induce seizures and cerebral ischemia. EMS should be contacted if consciousness is not regained within 60 seconds. Even when spontaneously breathing, patients might be experiencing hypoglycemia or stroke. If the patient's blood pressure is normal, low glucose level is most likely the problem. If the patient's blood pressure is alarmingly high, they may be having a stroke.  

Proper training and thorough preparation are very important for dental practicioners to deal with medical emergencies. Every office should have a written emergency plan and every staff member should be trained in basic first aid procedures and basic life support. Following the emergency event, a postemergency assessment of the situation should be done with all those involved evaluating each other’s performance. Also, make sure to document emergency treatment rendered. Are we really ready to deal with all of this on our own? 



Fonner DDS, Andrea;  Reed DMD, Kenneth “Be prepared – How to handle a medical emergency in the dental office.” Dimensions of Dental Hygiene. May 2013; Vol 11(5): 48–51. http://www.dimensionsofdentalhygiene.com/2013/05_May/Features/Be_Prepared.aspx 

Malamed SF, Mosby “Medical Emergencies in the Dental Office”, 5th ed, 2000 

Protzman, Sue; Clark MS, REMT-P, Jeff; Leeuw MS, CDA, Wilhemina. “Management of Medical Emergencies in the Dental Office.” DentalCare.com: Continuing Education. January 20112. http://www.dentalcare.com/media/en-US/education/ce445/ce445.pdf