Sunday, July 31, 2011

Episode 33/500: PDL Injection with 30 gauge short needle

I've now made it common practice to provide most of my endodontic patients with a PDL injection prior to beginning treatment.  I've learned that there are short 30 gauge needles available, which make the PDL injection much easier than with a conventional length needle.

BTW, that's my workout buddy in the background commenting on my saddle chair - he's Dr. No Rep.



Episode 32/500: Closed Tray Final Impression of Dental Implants

Here is a quick video of a CLOSED TRAY impression technique for Nobel Biocare Wide Platform Implants.


This is using a stock alginate tray which has been prepared with VPS/PVS adhesive.


  1. Ensure impression copings are (at least) hand torqued down.
  2. Take a radiograph to ensure impression copings are fully seated on implants.
  3. Air dry copings and region
  4. Place impression material around impression copings (in this case it was light body VPS/PVS)
  5. Place closed impression tray over impression copings.
  6. Wait for set and voila!


Episode 31/500: Hot Tooth Algorithm and Management

This is the patients' and dentists' fantasy come true - incomplete anesthesia during an endodontic procedure.  Wow.  How many times has this happened to me.  Too many to be proud of.  Both patient and myself are walking on eggshells and sweating bullets at the same time.

Symptomatic Irreversible Pulpitis (SIP) - You know, the patient who comes in the clinic complaining of lingering thermal pain, spontaneous pain, or an acute apical abscess - and - you wish you could Rx antibiotics and get them to come back in 3 days.

Nagle et al (Triple O, 2000) published an article regarding systemic penicillin on pain in untreated irreversible pulpitis.  No significant difference was found in spontaneous pain, percussion pain or analgesics taken.  Don't Rx antibiotics unless the patient shows signs of systemic infection (fever >100F, etc)

So, how do we manage these cases clinically?  Cross our fingers?  Hope?  Try this algorithm which was recently reviewed by our Endodontic Mentor, Dr. Crossfit.

Dx:   Symptomatic Irreversible Pulpitis of a mandibular tooth.
  1. IAN Block (once with Lidocaine 2% (epi) and then with 0.5% Bupivicaine (epi).
  2. Intraosseous (X tip/Stabident) with 3% mepivicaine.
  3. Cold test - if no response to cold - Initiate endodontic therapy.
  4. If positive to cold test, then give another IAN block with 3% mepivicaine and repeat cold test.
  5. If cold positive again, reappoint in 7-10 days.
  6. Rx 3-10 days of NSAID tx. No Antibiotics Rx'd unless indicated!


Episode 30/500: Greater Palatine Anesthesia with Ice - Take 5

Post - chops busting, here is a video by our endodontic mentor on a fellow resident demonstrating the correct greater palatine anesthetic technique.  This is take 5 and we already numbed up his other side (hence the hemorrhage).

Also, thanks to Ice Latte, our Perio mentor, for initiating this chop busting session.  To both of you guys, I am grateful.



Episode 29/500: Mouth Prop for the ages

If you have ever sat in the chair for longer than 20 minutes, I can guarantee that your jaw is going to get tired, sore, or fatigued from being open - especially if it's for a root canal on a maxillary 2nd molar.  Good times.

Get your patients to use a mouth prop - most like them.  Maryse, if you're reading this, I'm still right!  This will allow them to suffer comfortably much longer through those calcified 2nd molars.

Child size = adults
Adult size = horses



Friday, July 29, 2011

Episode 28/500: Adjust crown contours and polish fast

There are so many different methods in dentistry to achieve the same goal.  I am look forward to folks posting comments to discuss how they accomplish the same tasks - in a different way!

Here are 2 methods to quickly adjust the contours of a crown (gold/porcelain) and polish them quickly:

Rough abrasive wheel
Diamond impregnated disc

These tricks sped up my adjustment/polishing 10 fold.



Episode 27/500: Screw Retained Implant Crowns are back from casting.

It happened in a flash - the screw retained implant crowns were invested, burned out and cast in type 3 gold within 2 days.  This is a continuation in a series where I used UCLA abutments/E4D burn out blocks to restore Nobel Biocare Wide Platform implants that I placed 6 months ago.   This patient is leaving us in 2 weeks and we needed to get this completed ASAP.

Here are the screw retained crowns back from the lab and ready to be adjusted prior to the try in appointment with the patient.  I have some sweet new tricks on gold polishing that one of our prosthodontic mentors, Dr.K, graciously demonstrated to us.

Also, here are 2 radiographs of the implants.  The first radiograph is prior to removing the healing abutment.  There was a disconnect in my brain regarding platform switching (this was my first implant placement case) - hence the Narrow Platform healing abutment on a Wide Platform implant.  More on that later.

The second is a radiograph to ensure that the impression coping is fully seated prior to taking a final impression.  An impression video is coming soon.



Thursday, July 28, 2011

Episode 26/500: Complete Denture Workshop - Final Wax Try In

A prosthodontic mentor of mine - let's call him.....Dr. Dray - was a prosthodontic instructor at a dental school in San Antonio for a number of years.  During that time, he had the GREAT idea to take some video of one of the most elusive ballets in dentistry - Dentures.

My denture poem:

I left dental school confused.
I entered into practice confused.
I entered into residency confused.
I am in residency less confused.

Watch as he and his partner (Robin, perhaps?) tackle the final wax try-in for a complete denture.  It is because of this man, many students have bettered their knowledge of plastic teeth.

As I receive these videos, they will be uploaded.



Episode 25/500: Treatment Planning Case #1

One of the most critical things I've learned in the past year is how weak we are at treatment planning.

I will start uploading a number of cases with the intent of having you comment on what you would do for this patient - ie - a comprehensive treatment plan that is reviewed by specialists.

I have uploaded clinical images and radiographs (flickr) of the following 25 YO female patient who presented with the following chief concern:

"I had an implant placed 3 years ago and I would like to have a crown on it.  I don't have any pain.  I'd like to get all my teeth fixed so I won't have any more teeth breaking."

Med Hx:  No medications, no allergies, no past surgical history
Recent Dental History:  Non Surgical Root Canal Treatment (2 months ago) #4 and #6
Caries:  #2, 14, 26
Probing depths:  All <3mm

What is your comprehensive treatment plan?  My treatment plan will be posted in 7 days.



Treatment Planning Case #1

IMG_6101IMG_6060IMG_6062IMG_6064Case 1 MaxillaCase 1 - Mandible
Pano Patient 1IMG_6102IMG_6103

Treatment Planning Case #1, a set on Flickr.

Photos and Images for the TPC 1

Wednesday, July 27, 2011

Episode 24/500: Greater Palatine Anesthesia - Ice Stick

Our Chief Endodontic Mentor (Dr. Crossfit) is a manimal when it comes to crossfit.  However, he is a gentle giant when it comes to anesthesia.  I remember briefly reading an article a few years ago in the Journal of Endodontics regarding topical ice application before palatine anesthesia.  I tried it with endo ice (yes, it burned) and never did it again.  Dr. Crossfit mentioned that I should try the "ice in a 3cc syringe technique".

Topical ice: A precursor to palatal injections
Henry Harbert DMD
Journal of Endodontics
Volume 15, Issue 1
January 1989, Pages 27-28

Pro:  It works.
Con:  Not much!

Let me know how it works out.


Episode 23/500: Simple trick to hold implant crowns

My haiku poem for polishing crowns

Crown polishing
In front of patient
Crown flies across room

Here is a neat trick to hold onto your implant crowns when fiddling with them (ie polishing, waxing, staining).

Use a lab analog as a handle.



Tuesday, July 26, 2011

Episode 23/500: Facebow 101 - Arc of Closure

Does anyone ever really understand the reason why we need to use a facebow.  I left dental school still confused about it's practical purpose.  So, like everything else, I memorized the answer for boards, and that was that.

These days, I really do need to know why to use a facebow (Getting pimped on ridiculous trivia is a way of life for a resident).  There are probably hundreds of reasons to use a facebow, however, here are a few basic ones that I hope can help explain the ever elusive facebow.

Thanks to my camera lady for your help.



Episode 22/500: Endodontic Differential Diagnosis - Case #1

This is the first in a series of endodontic diagnosis cases that have challenged me (while my endodontic mentor watches me sweat) and I want to post them for you to try to figure out the correct diagnosis.

I will post "our" answer in a few days.  We have started treatment on this patient which has resolved her symptoms.

Case #1
This patient presented to our Endo clinic for an evaluation to re-treat #19.
Here is a copy of my initial eval:
CC:  36 YO presents w/ a CC of "I have had continuous pain to my lower left jaw for the several last yrs,"
#19 (1st  mand molar)- Pt had large carious lesion which was restored, fol by crn, fol by endo to remove pain.  Pain still remained following treatment.  Endo completed 6 yrs ago.
#18 (2nd mand molar) - Direct composite restoration 7 days ago, tooth has increased sensitivity to cold (+++ Fleeting).  
Med Hx:   No meds, no allergies.  PSHx:  None, NKDA
E/O:  Pain to palpation Lower Left approximating the angle of mandible
I/O:  See endodontic testing table
Patient wants extraction of Mandibular Left First Molar (#19/#36).  However, during the consultation, it appears that she may have changed her mind regarding extraction first molar and may be amenable to retreatment.  

Monday, July 25, 2011

Episode 21/500: UCLA Abutments and E4D Burn Out Block Crowns

Monday morning.  I was thinking about this ongoing screw retained implant crown case over the weekend and was debating using UCLA abutments instead of stock abutments.  I talked earlier about our decision to go with screw retained crowns.

Well, it turns out that in Dr. K's office, there were 2 Nobel Biocare UCLA abutments just praying to be used.  I milled out 2 acrylic Burn Out Block crowns and luted them to the abutments.  Total time:  1 hr.  Time saved from waxing:  Lots.

I'm stoked.  The next step is to invest and cast the crowns and abutments.



Episode 20/365: A Smooth Method to anesthetize the Anterior Maxilla - taught to me long ago.

Today, I was performing a maxillary esthetic crown lengthening procedure and wanted to show you a secret I was taught a number of years ago.

As you travel posteriorly from the lips, the ability of the patient to perceive pain decreases.  If you look at the homunculus below, it is fairly apparent that the lips are sensitive - lots of proprioception.  The idea behind this method is to initiate local anesthesia at the canines.

Step 1:  Place some LA at the canines, massage it anteriorly, wait a few minutes, finalize local anesthesia at your site of interest, or:

Step 2:  You can re-enter the mucosa at the canine region that you just anesthetized and direct the tip of the syringe anteriorly under the mucosa.  Deposit anesthetic slowly.  The patient's rarely have any sensation of pain if you don't penetrate the mucosa.  Pretty neat.  Thanks Shea.

Let me know how it works out for you.


Step 1:

Step 2:

Episode 19/500: Great Pedodontic advice from our Pedodontic Mentor

Our Pedodontic Mentor is a wealth of knowledge and experience.  He has passed on perhaps, one of the greatest tidbits of Pedo information I have encountered.

"Mom, Dad - you need to brush little Johnny's teeth until he can tie his shoes."

In all (and I mean ALL) of the high caries kids that we see, which is every child.....the parents swear up and down that the child/parents brush the kids teeth 2 times a day.  It's obvious that little Johnny plays with a toothbrush 2 times/day, but effectively brush?  Nope.  Not at all.

This simple direction gives the parents an effective visualization - Shoe tying:

"I can't wait until Johnny can tie his shoes, b/c he'll be able to do it himself and stop bugging me!"

Otherwise, it's too easy to send the kids into the bathroom to "brush" their teeth - a few minutes of calm in the household.

So, the next time you have parents (new or with young kids), let them know the bottom line up front - "Until little Suzie can tie her shoes - you, Mom and Dad - are the SugarBug Busters."



Sunday, July 24, 2011

Episode 18/500: KODAK 9500 Cone Beam CT

Imagine you could use a CBCT.....

I couldn't believe my ears when I found out that we had access to a Cone Beam CT.  We use it for hard/(soft) tissue pathology, implant placement, orthognathic surgery, and TMJ surgery, to mention just a few.

Here is an overview of the model that we use and it in action.  I have a number of cases that I will post with my radiologist colleague talking you through them.  It is rare that we have the opportunity to listen to how a radiologist reads a CT, and I want to take full advantage of it.



Episode 17/500: Ivoclar Optragate

If you viewed the Odyssey Navigator laser show a few days ago, you may have seen this isolation mechanism in the background.  I used it to retract the patient's cheeks.

I see this as a valuable tool for Class 5 restorations, perio surgery, orthodontics, crown preparations, etc.

Remember - Throat pack if not using a rubber dam.  It's been pretty close for me and patient aspiration - don't let it happen to you.



Episode 16/500: Literature Review - OAT (Oral Anticoagulant Therapy) and Dentistry

Here is my 2 min take on this systematic review (my review article for this month's current literature review) on OAT from 2007.

Aframian DJ, Lalla RV, Peterson DE.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Mar;103 Suppl:S45.e1-11. Review.

Episode 15/500: Screw Retained Implant Crowns - White Board Discussion

This is a quick discussion on why I am using a screw retained implant crown to restore implants #30/31.



Saturday, July 23, 2011

14/500: E4D having problems scanning titanium implant abutments.

I still cannot get the E4D to scan titanium implant abutments.

I have placed Snappy 4.0 mm Nobel Biocare stock abutments on the implant lab analogs to initially scan them with the E4D CAD/CAM to mill e.max crowns.

One of our prosthodontic mentors, let's call him Dr. K, suggested that we restore the implants with screw retained crowns.  His main concern was the removal of cement from the crown/implant interface following luting.  The implants (#30,31 or #46,47) are approximately 4mm subgingival and removal of the cement will definitely be difficult.

1.  Scan abutments with E4D, mill burnout blocks (plastic blocks)
2.  Lute the plastic crowns to the stock abutments and invest for casting.
3.  Burn out the pattern and cast gold to the abutments.
4.  Deliver screw retained implant abutment crowns.

This video highlights my workaround for the inability of the E4D to scan titanium implant abutments properly.


Episode 13/500: E4D CAD/CAM Onlay Prep Problems

I have grown to appreciate CAD/CAM technology. (We have both CEREC and E4D systems)

However, I'm going to tell you that switching to CAD/CAM takes patience.  A lot of it.

1.  Steep Software Learning Curve: Even with the advent of user intuitive interfaces - it's still a can tweet me to ask questions @ashleymarkdmd

2.  Constant milling machine maintenance.

3.  Digital impressions:  I'm still not there and it takes dedication to get to a decent level of ability.  It's easier for me to snap a triple tray, pour it up and scan it on my own time.

4.  Tooth preparations have to be within a fairly strict set of parameters, or the restoration won't fit.


Episode 12/500: Product Overview: Great Lakes NOLA

Where was this system when I was in dental school?  Why do all the secrets of dentistry slowly come out of the woodwork 10 years after graduating?  This product alone continues to feed my passion to spread the word about those hints that aren't in a book/literature.

The Great Lakes Nola Dry Field System is a gem.  Although we primarily use this for ortho, I can forsee this being a diamond in the rough for many things - including CAD/CAM - although, now that I think about it, we also have the Isolite.

The Nola is autoclavable.
Isolite has a light and bite block.
The Nola uses the existing saliva ejector suction line, and doesn't have illumination.

Hmm...the only minus I can see with the Isolite is that after repeated use, the light contacts in the control head assembly wear out and then the light doesn't work.  I'm sure there is a workaround/fix.



Friday, July 22, 2011

Episode 11/500: Use a model to discuss treatment options

My dad loves fluorescent orange spray paint.  He must own shares in spray paint b/c as a kid growing up, he spray painted EVERYTHING with his name - the lawnmower, the tractor, etc.

The point is that the easiest way to discuss something with a patient is to have a model.  We've all drawn pictures on tray paper....must I say more?


Thursday, July 21, 2011

Episode 10/500 - Implants and Gingival Moulage

I ALWAYS wondered how they put gingiva on dental casts - especially for implant cases.

Well, as usual, it's really simple.

Soft Tissue Moulage.

It definitely serves a purpose at times - I can think of a few situations:

1.  Anterior implant cases where you need to develop the emergence profile of the restorations according to the gingival architecture.

2.  The implant body is 3-5 mm below gingival tissue and pouring the coronal gingival portion in stone would cause some difficulty. (You wouldn't be able to access the coronal portion of the implant analog).



Wednesday, July 20, 2011

Episode 9/500: A gentle method to provide palatal anesthesia.

Slow palatal anesthesia through the interdental've probably done it before, but this is a hint for some new folks on the block.

I remember I was in dental school and a dental hygiene class was learning to give local anesthesia.  I didn't have anything to do that Saturday, so I decided to be a guinea pig and try to pick up girls.  Well - I didn't pick up....and...I learned a great lesson.  Palatal anesthesia is awful.  Incisive papilla anesthesia is even worse.

The scenario.  Test time at the end of the day for these hygiene students.  Mission:  8 injections, Time:  5 mins.  The last injection was the incisive papilla.  After 7 injections, I was white fisting the chair, expecting the worse for injection #8.  "Ashley, are you ok?" she asked.  "Yes.  Let's get this over with." I replied.  As needle #8 (dull by this point) was thrust into the soft, tender gums behind my 2 front teeth, my feet raised off the patient chair and I lost all circulation to my hands.  "Are you ok?" "mmmm...Of course...mmmmm" I mumbled...

So, for palatal anesthesia, I use this simple trick.  After infiltrating around the tooth/area to be anesthetized, I wait for the patient to marinate for approximately 8 mins.  By that time, the interdental papilla is usually numb enough to slowly slide a #30/#27 tip and deposit anesthesia buccally to palatally.

I watch the palatal mucosa in a mouth mirror to watch for tissue blanching - a sure sign that palatal anesthesia is beginning.


Tuesday, July 19, 2011

Episode 8/500: Provisional Stent Fabrication - Extrude Putty

This is a neat case in which we're going to prepare a stent which will be used to fabricate a provisional restoration on an implant.

Hints in this video:

1.  Don't roll the putty into a ball during mixing - the heat developed speeds up the set - fast.

2.  Watch how I roll the putty onto the cast - a prosthodontist showed me this last year.


Episode 7/500: Ivoclar Odyssey Navigator Diode Laser- Implant Unroofing

Today was pretty exciting.  I'm using the laser to unroof the implant with the hopes to place a provisional 3i abutment and provisional restoration.  I later learned that the implant is a type that we don't have tools for......hmm....the downside of implants.....Too many companies selling.....yes....titanium.

I was capturing some video when a buddy walked in to the office and looked at me with a camera video recording and me with those funky goggles on.....

Preoperative Image.  That implant is somewhere in there.

Postoperative.  IT LOOKS BAD but IT'S NOT.

Remember - use H2O2 afterwards to clean up the surgical site.


Episode 6/500: Ensure your impression coping doesn't move in your impression.

A resident colleague of mine (an extremely bright head and neck oral radiologist) is thinking that in 50 years or so, dental implants will be gone - and the new will be tooth regeneration.  Hmm.......I"ve got my thoughts on that, but for the meantime, we've got dental implants.

I've been pouring up enough dental implant impressions lately to know that the impression coping is moving when I vibrate the the impression.  The fix:  Cyanoacrylate.

I also just learned about adhesive accelerant - it significantly speeds up the set of cyanoacrylate.



Monday, July 18, 2011

Episode 5/500: Accurately articulate dental casts

This is a great, simple technique that's worth it's weight in gold - really..

Take a rotating disc,  eg. a brittle separating disc and/or a diamond separating blade and notch the max/mand casts at points of tooth interdigitation.

This technique is much more accurate than using a marker to draw connecting lines between the max/mand casts.  In the video, the lab tech who mounted this 3 unit FDP used a Galetti articulator, and the mounting was spot on.

The video needs work - but - the idea is there.


Episode 4/500: Scandex Saddle Dental Operator Chair

I blogged about back pain before and I'm not into dental operator chair sales - however - when I was stationed in Belgium, working alongside our European colleagues, I couldn't help but notice that they all used saddle chairs.  I"ve been in this AEGD-2 yr program for 14 months and my back is killing me.  From all the specialty rotations - man..... So, I googled saddle chair and some cheap generic ones popped up on ebay, however, surprisingly, there were few saddle dental chair companies in the US.  Scandex.US kept popping up -  I called Sven - and in a few days, this great chair showed up.  This is a demo model ($150 USD cheaper) - hence the "carbon blue" - but - I"m in the military, so color in the dental office really doesn't matter.

But - it's not only the chair - it's just a small piece of the puzzle.  Keeping your ab's tight, shoulders back in their "sockets", and remembering to keep your posture is critical.  So is fitness.  Dentistry is work - and - your body needs to be fit.

Call Sven - he's a Swedish gentleman.


Sunday, July 17, 2011

Episode 3/500: What's an Implant Lab Analog and Dental Jack Hammer? Yikes!


Ever wonder what a dental lab does to minimize costs?  Ever wonder what YOU could do to minimize your costs and recapture some of those charges that the lab bills you?

Nothing sexy today - however, I wanted to show you how a dental lab may use air hammers to remove analogs from casts - or - well - anything that can be broken by a mini jack hammer.  I didn't even know these things existed on the mini level.

You'll probably never use one - but what the heck - might as well see one in action.

Episode 2/500: Dentist Back Pain -

My upper right shoulder is starting to get on my nerves.   I've changed about 4 things in my life to help ease the pain:  Posture, operator chair, bigger monitor at home and an old piano stool at my desk.  

Back pain is a major concern for us teeth people.  I think the only guys/gals who can get away with little to no back pain are endodontists using microscopes.  For the rest of us, it's hard back labor.  Not as difficult as the guy riding the jack hammer 7 hrs a day, however, poor posture does catch up to us. Since starting this residency - my upper right shoulder pain has increased from 0 to about a constant 7.

Crossfit has been a way of life for the past 6 years, and I just completed the Crossfit movement and mobility trainer course.  The Crossfit ideology keeps me fit for work and now, the mobility cert has given my posture an overhaul. 


Episode 1/500: ATD: Where the Invisible becomes Visible

This has been my dream - a mixing place for Dentists, Dental Students, Dental Companies, Dental Lab Techs, Patients, and current/future General Dentistry Residents....

Where the Invisible Becomes Visible

This is a compilation of my day to day learning in a 2 year Advanced Education in General Dentistry residency.

I've always wanted to pass on so many of those little clinical and laboratory hints that I have learned from others.  This is a place where I can speak of those techniques from specialists themselves - including prosthodontics, endodontics, oral surgery, periodontics, and pedodontics.

I review anything I can get my hands on - for you - and me.

ATD:  All Things Dentistry