Today I was back on the clinic for what could only be yet another prudent learning experience. From last time I had high expectations for today’s procedural standards. As a result of an increased self awareness and increased knowledge base from my first shadowing, I feel I was much more interactive with members of the dental team and with patients themselves. I remember the first time, I found it difficult to talk to patients as I found it quite daunting. I feel that I have managed to overcome this and find it much easier to communicate with patients and consequently with the multidisciplinary team. First time round I found it very difficult to adjust to the clinical setting, however this time I settled in almost immediately. I felt more self confident in my communication skills and awareness i.e whereabouts of required materials e.g. instruments from the dispensary.
I was much more familiar with professionalism this time and ensured I dressed professionally, wearing a neatly pressed lab coat, closed-toe shoes, did not wear jewellery and kept facial hair trimmed. It was a great opportunity to enforce my knowledge of infection, prevention and control I broadened last time. I was more confident in recognising zones (clean and dirty), hand washing procedures and PPE from seeing its realities of practice last time.
Today’s patient presented with a fractured crown on the upper right canine (quadrant 1, number 3). Prosthodontics is an area I was unfamiliar with before today but further research and reading heightened my knowledge and interest. Preparation and provision of crowns (tooth-shaped cap that sits on the tooth to restore its shape/size/strength) helps protect natural dentition while providing the illusion of sound tooth structure [1]. A new crown was required, so an impression was taken to be sent to the lab while the patient was given a temporary crown for the time being.
The original crown was fractured due to masticatory forces. I hadn’t been aware of the effects of this force so I researched: normal incisal bite forces average between 130N and 230N [2]. Metal-ceramic crowns are stronger than all-ceramic crowns, this factor along with aesthetics are considered when planning treatment.
With discussion, I learned that the process for making a crown for a patient usually takes two separate appointments. The first appointment involves: i) Preparing the tooth ii) Taking an impression iii) Placing a temporary crown. The second involves: i) Removing temporary crown ii) Placing permanent crown. This case involved a fractured crown, so the “preparation” needed was the removal of the original crown. What went wrong in this step was that the crown was placed in such way that it was bonded to the adjacent teeth thus a drill (high speed dental hand-piece with a burr placed at the tip – which also sprays water) was used to vertically cut the crown for removal. I learned about this technique: cotton roll placed in the gingiva superior to the tooth with left hand suction and right hand drilling. I’m now aware that this is a viable option for crown removal if it does not come out with ease. [3]
From this year’s dental materials lectures, I was familiar with the procedure of taking an impression. Seeing the reality of this practice provided me with an opportunity to self-assess my knowledge of impression materials. The stock tray was placed in the clean zone and two layers of adhesive were applied and allowed to dry in-between applications. A PVS silicone impression material was used (polyvinyl siloxane – non aqueous elastomeric impression material/elastomer). The choice for this was its accuracy and dimensional stability – due to the lack of polymerisation by-products, hence pouring of the material is done with ease [4]. I had not been aware however that PVS requires a dry field as it’s hydrophobic in nature [5] – something I must be aware of in practice. Observing impression taking techniques today, I’ve realised it’s vital that I must develop a reliable and repeatable technique of taking impressions to ensure utmost accuracy as a dentist.
The student cleverly allowed the patient to sit upright for comfort while taking the impression, highlighting that patient comfort is pivotal and mustn’t be forgotten. Light bodied material was placed on the tooth while medium bodied material was placed in the stock tray.
Aesthetics are vital for prosthodontics as it gives the illusion of sound tooth structure. The demonstrator aided the choice of shade by examining the tooth and selecting it based on a scale measured A1-D4. I read up on this process, discovering that dental colour scales have been devised, one of the earliest being the AH Munsell system which incorporates: wavelength (hue), saturation (chroma) and its luminance reflectance (value) [6]. I gained an awareness of this careful process, which requires impeccable attention to detail in order to provide a high standard crown.
Communication was highlighted again today. Both students had excellent methods of communicating with patients and possessed the ability to use colloquial language to explain the reasons and steps behind each procedure. Today’s student described a crown “like a lagging jacket going over the hot pressure boiler”. I was immensely impressed with how they knew exactly how to talk to their patients without hesitation. I learned that this is key to gaining informed consent for procedures. It’s been shown that formalities of consent can confuse patients and often they find it difficult to comprehend the phraseology of consent forms [7] From both shadowings I was reminded that patients must be given all details about their condition, effects and the treatment plan (diagnosis and prognosis). The giving of informed consent cannot be done unless the patient is able to comprehend and explain themselves what the procedure being done is. I learned a lot form the students regarding this as they communicated in a way that the patients did not feel that their consent was simply a formality – enforcing patient autonomy and beneficence [8]
Now, having completed my second shadowing I am able to link certain similarities. Both shadowings dealt with treatments as: history, examination, diagnosis, treatment and care planning. I was taught that a comprehensive medical/social/dental history is an essential part of proper patient management and patients can confront dentists with very complex histories [9]. Hence, impeccable listening skills are also required to allow to patients to speak freely. What I never noticed before was how the examination of patients begins from the moment they step onto the clinic. Obvious causes of concern such as facial swellings and/or bleeding are instantly noticeable.
I found that my experiences of the clinic provided me with a learning platform in which I was able to integrate theory with the realities of practice. I gained a deeper understanding of the importance of the dental team and their roles and responsibilities for their patients. My experience linked didactic learning with practice and provided me with insight into dentist-patient interaction. Through research and my own opinions I’ve gained deeper appreciation for the combination and theoretical and practical learning in health sciences [10]. Through revision and reflection of material processed last year, as well as current material in RD2007, I maximised my learning experience on the clinic.