I usually don't write posts but I've been inspired by the events of today to talk about my experiences at La Clinica- Pittsburg. Like Melanie (above), I've been in this residency for the last 4 months. This is just a day in the life of a resident...
My first patient of the day needed a 3 unit bridge, from #7-9. She was previously seen by another provider in the clinic, and after the provider discussed the case with the director, Dr. Lai, scheduled the patient in my schedule for me to start on the bridge. The provider had already discussed alternatives options and fees with the patient and everything was taken care of. The patient was good to go. I was unprepared to see the patient as it was my first time interacting with the patient. I briefly discussed the case with Dr. Lai prior to starting and he guided me through what I need, even suggesting what order I should do things to get moving: Photographs, anesthetize the pt, triple bite impression for temp fabrication then start. He suggested I prep #7 and 9 first prior to extracting #8 so that there would be less blood to work with. He also brainstormed ways in which I could fabricate the temp after #8 had been taken out and suggested that I try putting a rubber dam on so that the extraction site would be blocked. Right before I started the prep, he sat down with the patient examined her with me. He asked me probing questions about what I expect to encounter during the procedure and patiently waited for me to closely examine my patient's dentition. Finally, I noticed that #7 was rotated and chipped and #10 was lingually offset from the central incisors. He explained to me how my prep for #7 would change due to the rotation and how I needed to discuss with my patient the need for #10 restoration/crown since after the fabrication of the bridge by the lab, #10 may look out of place and may not be in harmony with the other teeth. As I worked on the treatment (with my mind frazzled from trying to do the prep, extraction, and temp in my scheduled 2 hours), I would periodically check in with Dr. Lai and he would give me suggestions on what I could do, including take intraoral photos and placing the composite on the temp to even out the bridge so that the patient can have a better idea of what the outcome would look like. Luckily (or not, depending on how you look at it), my other patients for the morning were no-shows and I was able to spend time with the patent to do a good job. BUT had my other patients shown up, I could have asked one of the other providers to see if they could see my patient. That would not be a problem at all. After the appointment, Dr. Lai sat down and discussed the case with me and asked me how I could have approached the case differently. He had recently provided online lectures on staging comprehensive treat from his own resources for us residents to watch. Referencing these lectures, we discussed the need to take study models prior to treatment and possibly having a case wax up ready to present to the patient prior to the appt. He explained why presenting a comprehensive plan to the patient prior to treatment would help us anticipate treatment sequences and allow the patient to make informed decisions on her overall dentition and allows us to optimize her results.
That was just the morning.
In the afternoon, I had a pulpectomy scheduled. Usually prior to endo cases, Dr. Lai likes to go over x-rays and discuss treatment strategies prior to starting treatment. He usually asks how we're going to access the tooth, whether we're going to be using a rubber dam for caries removal or to access the pulp, and which rotary file system we'll be using (we have many to choose from including pro taper, vortex, GTX, wave one..) If we have any problems at all during the procedure, we can usually page him and even if he's with another patient, he would take a break from the patient and check up on us. The wait time is usually quick, like 5 mins at most.
Either way, my pulpectomy didn't show up.
I ended up seeing an emergency exam. My pt. was 5 years old. Her mom was concerned because #24 was growing in lingual to #O and tooth wasn't loose. I didn't really know what to say to the patient. My prior peds experience was rather limited. I ended up discussing the case with Dr. Lai and another general dentist provider. They told me that it's normal and that the tooth would eventually loosen. It would be worrisome if the child was older and the tooth is still retained with no movement. I promptly conveyed everything to Mom and they left satisfied. Had I not been able to turn to Dr. Lai, there is also a pediatric dentist in the program that would welcome any pediatric questions.
The last patient of the day was a complicated case. The patient had GERDS and heavy bruxism, wearing his teeth down to little nubs. He wanted to fix his front teeth. There's so much we could do for the patient, including full mouth reconstruction, which would include crowning most teeth and opening up his VDO. I discussed case extensively with Dr. lai, trying to consider which teeth may need RCTs, which teeth may be unrestorable, which teeth can get away with a build up and crown. We made plans for the most ideal treatment and another based on financial limitations. Even though the patient decided to go through the less expensive denture route, the treatment planning has been extremely valuable as I can factor in some of the problems while fabricating the dentures. For the rest of the treatment, I took centric relation records and face bow records. For CR, I used the leaf gauge technique, which is something that we just learned about yesterday when we watched a video on taking centric relation while sitting with Dr. Lai and peppering him with questions. For the face bow record, I used the Koi panadent system (again, we had recently been sent online videos on how to use the system). I wasn't too sure about whether I was taking the face bow record correctly, so Dr. Lai walked me through the procedure on the patient. At the end of the day, I was ready to run home. But Dr. Lai stopped me right before I dismissed the patient and asked whether I had taken any intramural photos of the case. It wasn't actually necessary, but he wanted me to practice my intra-oral photography skills. I'm so glad I did it because now I would be able to present the case for the residency case report if I wanted to. Since I was unsure about how to proceed with immediate dentures, I asked a prosthodontist for help with phasing treatment and she listed the steps that would be needed, including when to take out teeth, how long would have to wait, what other prosth steps would be needed next, etc.
This is just one day in my yearlong residency here. If you were to visit for just an hour or two, you may miss all of the great interactions between us residents and the other dentists. It really goes to show how much you're really learning and how supportive everyone in the program is. You get a sense that people here are trying to do the best they can for patients, even when factoring in financial limitations. I'm proud of the quality work that gets done here. You never get a sense that people are just doing work just to get by. Each procedure, no matter how big or small, gets carefully thought out.
At the end of the day, I got a text from the director, "Btw forgot to tell you good job today with all the complicated prosth cases you had, you handled them well!" (Awwwee, shucks)
