Monday, August 20, 2012

Episode 386/500: Local Anesthetics

Local Anesthetics - ...and dentistry.  Imagine if these drugs were not available and we had rely on other methods of pain management:

acupuncture, local anesthetics, pain control


vodka, local anesthetics, pain

jimi hendrix

and when I googled vodka, a picture of Jimi appeared..... so we might have had to use some of the chemicals that he was on as well to aid in managing pain if it weren't for Dr. Halsted and his "championing" of local anesthetics.  

What is the point?  Well, a few days ago, a couple of dental students were in the office and we were discussing what the order of neuronal blockage is for sensations following the application of local anesthetics.  Proprioception, pain, heat, cold, etc magically disappear in a specific order and reappear in the reverse - can you recall that order?

The relevance of this post has to do with the following image:

SIP, symptomatic irreversible pulpitis, cold test, endodontics, anesthesia, anesthetics

Translation:  For a mandibular block, a numb lip does not indicate pulpal anesthesia - however, a cold test/ept on the tooth about to receive endodontics will aid in determining if you indeed have pulpal anesthesia.

Perhaps there is a reason why (in the specific order of neuronal blockage) a cold test is an effective method of determining if you have pulpal anesthesia........TBC

Friday, August 17, 2012

Episode 385/500: Provisional Restoration (temporary) Block Technique

Avu23 - your dream has come true.  Ok, maybe not - but - as you mentioned - I didn't forget!  Avu23 requested some footage on the block provisional technique.  I"ll be honest.  I keep as far away from this method of doing things as possible.  I'd rather take some rope wax, carve a crown intraorally, fabricate a stent (putty or triple tray), then use that stent to fabricate a provisional restoration.

I had a race with Dr. In.Saini one day at 1600hrs.  He was sitting in his usual position (head down), struggling with the fabrication of a provisional restoration without a stent.  There was a glob of some sort of old school methylmethacrylate sticking to his hands while he was trying to roll it in a ball.  Yikes.  Glad I wasn't on the receiving end of that mess.  Mind you, he'd had a long day of sipping gin and juice at the computer and his hands may have been slower than he was expecting (just kidding).

So, just like my wife does - I offered to race and see who could complete a provisional restoration the fastest....well, it wasn't really a race.  I gently pushed him aside to give him a break and used this technique that I've used for some time.

I haven't watched this for a few months and I already miss Dr. In.Saini watching from his desk - aiding? to the videos!

So, I finally tracked down Dr. K who agreed to show you and I how to fabricate a provisional restoration out of thin air.  He is an amazingly kind and gentle man and was a pleasure to consistently learn from.

Dr. K likes to use SNAP (which is what type of acrylic?) when fabricating a restoration like a magician.  At times, I honestly thought that he'd have to reline that restoration due to polymerization shrinkage - but alas - I learned that SNAP has a very low polymerization shrinkage (I still can't find any literature about it), which may aid in preventing the need to reline one of these.  What do they say about assume?  Something about making an ass out of you and me.  So again, I learned another tidbit about PEMA (poly ethyl methacrylate).  Dr. K actually prefers to use bisacryl (Maxitemp or Luxatemp) when he has a stent, but, when magic is required, so is SNAP.

Thanks Dr. K.  

Monday, August 13, 2012

Episode 384/500: Alveoloplasty - Aaron Part - 1 of 2

Alveoloplasty - a simple preprosthetic surgical procedure that can facilitate the fabrication of an esthetic and functional denture (or FDP).  I always looked at the photos in surgical textbooks and wondered how difficult the procedure was.  It's typically not that difficult - there is a fair amount of planning involved - but - the procedure (like many), is straightforward.

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Preprosthetic cast surgery

We started off with a number of preprosthetic planning items, including cast surgery (as completed by Dr. Dray), and a wax try in to determine if preprosthetic surgery was indicated.  It was.  However, it's difficult to determine how much to remove vs how much mother nature will remove.  The maxillary right central incisor had been extracted a number of years ago and there was very little ridge resorption.  Perhaps, the surrounding teeth maintained the ridge - but - we elected to remove some maxillary osseous tissue.  Remember, we will obtain some extra ridge resorption by simply elevating a flap.

Here we go.

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Initial Incision

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Surgical Stent Try in

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Flap elevated - the osseous ridge prior to alveoloplasty

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
 Round bur about to be put to use

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Ridge following alveoloplasty

Alveoloplasty, alveloplasty, denture, surgery, extraction, complete denture, immediate denture
Sutured.  Next time:  Continuous

Friday, August 10, 2012

Episode 383/500: Composite Matrix - Custom

Dr. Queso - thanks for this composite matrix tip.  For those times/situations/locations where you don't have a sexy composite placement ring system - bets are that you have a tofflemire matrix floating around in some drawer or cabinet.

Dr. Q shows us how to modify that tofflemire to aid in placing a composite interproximally.

Thanks Ryan - you're a solid chap and I"m thankful for your support.


Tuesday, August 7, 2012

Episode 382/500: Checking for Denture Sore Spots

There are probably thousands of ways to check for pressure spots on the intaglio surface of the denture - Pressure Indicating Paste (PIP), Thompson Sticks, Wax, etc.

Aaron is back after one week following several maxillary posterior teeth extractions and anterior maxillary alveoloplasty.  Considering this was my first alveoloplasty, Dr. Partridge was nearby providing advice when required - a really simple surgical procedure that will help this young man.  The entire surgical procedure will soon be posted - the video production is in process.

Alveoplasty, extraction, denture, complete denture
Elevating the mucosa and periosteum after posterior extrations.

Alveoplasty, extraction, denture, complete denture
The type of bur/chisel you can use is up to you. I just found this round bur
easier to manipulate - cover up your arms b/c the debris goes everywhere!

Alveoplasty, extraction, denture, complete denture
Alveoloplasty ccompletted

Alveoplasty, extraction, denture, complete denture

Check with the surgical stent - it appears good to go.

Alveoplasty, extraction, denture, complete denture

Dr. Dray's biggest tip with regards to PIP was to ensure that the PIP is placed with light brush strokes in the same direction.  This stuff is difficult to work with on a good day (ie, there are many false positives - spots rubbed away during placement or removal).

alveoloplasty, extraction, denture, complete denture
Ouch. That just looks painful.  A sore spot on the canine eminence.

We'll talk Thomson Sticks next time.

Wednesday, August 1, 2012

Episode 380/500: Oral Sedation

I want to thank you for continuing with this blog.  We're in the middle of moving homes and with 3 young boys - wow...I can't upload videos b/c the bandwidth is super thin.

In the meantime....

One small, but fairly useful tip that was given to us by Dr. Hargreaves a looong time ago was with regards to oral sedation.  

oral sedation, benzodiazepenes

Before attending a great continuing education seminar by Dr. Haas in Toronto (Dental Anesthesiologist) (arounds 2007),  I would have the patient take their medication 1 hour before their appointment (at home, or wherever), and have their escort bring them to the appointment and wait.  I always wondered why some folks didn't really show any effects of the medication when they arrived.

Paient: "Yes Doc, I took the medication 1 hour ago. I don't feel any different"

Me: "Weird."

Turns out that perhaps, like myself, the patients may have been procrastinating - or - not taking the medication exactly on time.

For some of you - yes - you're thinking why didn't he just have his patients take the medication in the office and wait?

I'll try to one up you.  Ever heard about the gastric emptying reflex?  I hadn't either.

It turns out that the stomach empties itself automatically (hence "reflex") once it is filled to a specific amount.  I've tried to find some literature on the amount, but I can't - if you know some lit, please post it in the comments.

What is an average amount?  Maybe 8 ounces (236 mL) - some other websites have sited 12 ounces.  

Anyways, the point is that the faster you can get the medication into the small intestine, the faster the patient will succumb to its helpful effects....and several things including food will slow absorption.

So, what's the tip?

Have the patient fast for at least 8 hours before the appointment and drink approximately 8 ounces of water with the medication.  This has been my routine since learning of this tip - and I have noticed a difference in the speed of onset - it's faster.

Of course, there is the sublingual route and intravenous.  Just a note...some medications are not absorbed sublingually.

Thanks Dr. Hargreaves.


Episode 381/500: Alginate Impression Gadget

Well, here is that "thing" explained.  It sat on my lab bench top for almost 6 months before I broke down and wanted Dr. InSaini to demo it - but alas - he was gone.  Yes, I miss my friend who didn't stop talking nonsense about the minutia in biology, how the ameloblasts stop for coffee during their travels, etc.  He had this book sitting on his desk a few months ago: 

Like seriously - friend.  I asked him if he stayed awake.  He was able for a few chapters ....and then the stubbornness forced him to finish it.  Ouch.
Sadly, I was only able to comprehend what he was blabbering about during our senior year of the residency.  I learned so much from a great friend.  Our time together and your friendship is missed.  You as well Rico. Hope that last minute house packing was fun.

Ok, I'm wiping the tears away.  So, InSaini wasn't around and I had to see if this thing had any merit other than another dental gadget headed for the junk bin.  I think it actually has some worth.

What do you think?