Sunday, September 3, 2017

3 Benefits of Being a Military Dentist You've Never Heard Before (Companion Post to Dentistry Uncensored Interview)

[A couple of days ago, I was fortunate enough to record an episode of Dentistry Uncensored with Howard Farran (#888), a popular podcast where Howard interviews all sorts of interesting people from the wide world of dentistry (and beyond!). My interview should be up in about two months. Be sure to check it out!]

Coming into my decision to pursue dentistry with the Air Force, I had heard all the typical lines about why I should (or shouldn't) do the HPSP to pay for dental school.  I made the decision to join the Air Force prior to even starting dental school, so basically I had to hope that the benefits outweighed the risks like I imagined.

This post explores three themes from the book Uncomplicate Business, by Howard Farran. He mentions peopletime, and money as three pivotal factors in controlling your destiny as a dentist.  Don't miss how much you can learn about these 3 things while serving in the military! They are often forgotten points of learning by new and seasoned Air Force dentists alike.

These three benefits of being a military dentist are:

1. Not Enough People

If you have any desire to leave the Air Force after your commitment is over, this one point is huge.  I've heard Air Force dentists complain extensively about the difficulty in managing and dealing with co-workers, many of whom either did not want to be in dentistry at all or did not want to be stationed where they are stationed.  They blow this off as one of the downsides of being in the military.  WRONG!  This is, in my mind, one of the overwhelming benefits!

When in your career would you be able to work to motivate and collaborate with a group of people from all areas of life, from all over the country, who may or may not even want to be doing what they're doing?  Working through this problem, rather than blowing it off, allows you to hone your leadership and people management skills in ways that your civilian dentist counterparts will likely never experience.

The other factor is that you cannot simply re-hire to fill vacancies. Staffing decisions are made at a higher level than your local clinic level, so clinics are frequently understaffed for all the needed positions.  The biggest area I see this is in how many dental assistants there are.  In a typical private practice, you usually have more dental assistants than dentists.  In the Air Force, it's typically a 1 to 1 ratio, meaning there are several 10-15 min breaks during the day where the assistant is breaking down a room or setting up a room and you're in your office working on notes or other things.  Realizing you have the capacity to work 2 or 3 times as much as you are can be discouraging, but just use that opportunity to get treatment done quickly so you can have free time to do other things.

2. Not Enough Time

I ended the previous section talking about how much free time you have in a given day, so you're right to be skeptical for a moment.  The problem (or as I'll argue, the benefit) is that on a larger scale, your time is not under your control.

You should always be striving to do more, and time is our most valuable currency.  In the military, or any government job, the concept of working overtime isn't really feasible from a dentist's perspective.  Being in a non-commander role, it's not really up to me to rally the herd and stay open an extra hour each week, or shut down on a Friday and fly everyone to Anchorage for a teamwork seminar.

Time is always against you, but in the military, this is especially pronounced.  Like I said in the previous paragraph, your time flexibility on a scale from 0 to 10 is somewhere closer to that 0.  Having to squeeze 10 unexpected patients into an afternoon that was set aside for military training so that the base can send those people to Guam by next week, are the kinds of time constraint issues you run into.  You exist to keep the Air Force running smoothly.  Your time is the military's time.  And if you can figure out ways to creatively control your schedule to continue improving your skills in this environment, you'll see huge benefits when you step out and finally get to control your own time.

Fortunately on a day to day basis, you do have control over the lengths of procedures, just not on the actual work week or overall schedule itself.

3. Not Enough Money

Imagine you're out and about on a Saturday when suddenly the craving for hamburger hits.  You and your spouse drive to a nice place to have lunch and then come home.  Does this seem like a money-intensive process?  Probably not.  Why not?  It costs money to put fuel in your car, it costs money for the wear and tear on the car, you need to have purchased car insurance and have a license to drive the car, not to mention the cost of the meal when you arrive. Did you consider all that?

Ok, now imagine you're 16 years old again and you want to have lunch with some friends.  You don't own a car and you don't have gas money because you rely on your parents for an allowance and you spent it all on a video game last week.  So your friend (who is 17 and has a job) decides to help you out.  They come pick you up and buy your meal for you.  It's a little annoying but they don't mind.

Being in the military is like being 16 years old again.  You have almost no control over the amount of your "allowance" that comes in each month and you foot the bill for your own dental license and often for your own CE courses.  You hope the "allowance" comes into the clinic on time so you can buy what you need and if it doesn't, you're going to have to choose between gas and food.

This sounds a little extreme, but it does happen.  The government has situations where they can't promise money to a medical clinic or dental clinic, and so your clinic may be forced to operate on a drastically reduced budget.  So what's the benefit in that?

Learning how to operate a clinic for 5 months on a budget roughly 35% of its normal size when you're in charge of ordering supplies for the clinic, forces you into all kinds of new and uncharted territories.  Finding out which items are crucial to not only keep the clinic open, but to maximize the potential to meet the specific mission of your base, is no easy task.  Saying "no" when people ask if you can buy this or that, or completely reorganizing every treatment room to streamline your supplies so that absolutely nothing goes to waste, are two delicate but vital strategies.  Some day you'll leave the Air Force and be a grown up dentist, not reliant on the Air Force's "allowance" anymore.  But those important financial pivot points will already be part of your natural decision making process.  Lucky you!

Not having money obviously means not having what you want.  But often times the standardization of the clinic will trump your preferences.  The benefit here is flexibility.  You'll need to learn to work with other doctors (and even your assistants) to come up with supplies you can all agree on.  It may not be your favorite bonding agent, for example, but it's cheaper and more efficient and the expiration dates are 2 years out, so it fits well within your clinic's goals.

These are the type of weird supply decisions that have to be made when there are people moving in and out of your clinic every few months.  We are fortunate enough to have such a tight-nit group of doctors at Eielson that agreeing on standardized supplies is rarely a problem.  Again, knowing the clinic's main mission helps clarify and point us in the right direction.

Here are questions we have had to ask ourselves at Eielson when considering changes in supplies:

Should we focus on getting every doctor exactly what they want, or take into consideration that assistants will get confused if every treatment room is set up differently?

Do we buy burs for $0.98/each and put the sterilization burden on someone to package all of these burs for us, or do we order burs that come sterilized from the factory for $1.01/each?

If diamond burs are not consistently cleaned properly, or sometimes get dull without the next doctor knowing, is it worth it to re-process these or should we move to single-use diamonds?

The list goes on and on.  The supply game is a hard one to play, especially in light of the money game!  But learning how to make compromises and think of the clinic mission every time you make a supply decision will lead to huge benefits in how you eventually think about your own practice some day.

I hope this post was helpful.  My goal here was to pick out 3 topics (people, time, and money) that are most often cited as downsides to military dentistry and show you how, when looked at from a different angle, are actually 3 of the biggest benefits. As always, email me (see right side of blog) if you ever have any questions!

Monday, July 10, 2017

Graduating Soon? How to Rank AEGD Bases.

Sometimes in life, patterns pop up to give us hints.  In this case, I've gotten almost the same email 3 times in the last 4 days!  So... I think it might be time to visit this topic in its own post.

1. Location, location, location.

This is, in my opinion, the overwhelming and... essentially... only factor you should consider when ranking your AEGD bases.  AEGD experiences vary significantly based on who the faculty is at your AEGD, and location has almost nothing at all to do with this.  Pick a base that's located where you want to be and don't give it a second thought.  If you just can't help yourself and want to give it a second thought, keep reading.

2. Faculty.

This is very hard to pin down.  Faculty members are coming and going all the time, making it nearly impossible to make a judgement call on an AEGD base on this.  However, if you must, you can consider emailing the residency directors at each base and requesting to get in contact with some of the current residents.  You can pick their brain about who might be there and what experiences they have been offered as far as number of crowns, implant experience, etc.

3. Other stuff.

Travis AFB has an Oral Surgery program.  Theoretically, this will limit the number of cases flowing to the AEGD program.  However, it's well known that AEGD residents are expected to do wisdom teeth cases, so it's not as if you're going to run dry on them.  I wouldn't put a ton of weight into this.

Your AEGD base of choice has virtually no bearing on what base you might get after your AEGD.

That's about it!  In summary... location. Go where you want to go and don't worry about the other details.  It's a lot to track down to rank bases that are really just telling the Air Force what you want and aren't a guarantee anyway.

Saturday, February 4, 2017

Dental Tips from a Newbie

I've been at this dentist thing for a few years now, but I'm constantly running across different tips and tricks that make my life easier as a dentist.  I wanted to share them with you guys, because sometimes in the military, we have to be creative with the supplies we have at hand!

Hemorrhage control in restorative dentistry:

This is tough sometimes.  You've got a patient that has less than ideal hygiene and when you drop the box for your prep below the gingival margin, inevitably you get some bleeding right into where you're working.  Here are some tips to help you out.

1. Viscostat Clear on a cotton ball - Viscostat Clear is an excellent product that is comprised of 25% Aluminum Chloride to help control minor hemorrhage.  Emphasis on "minor".  It will not stop the gushers from gushing but it will keep minor hemorrhage at bay.  However... if you saturate a small cotton ball with it and use pressure against the hemorrhaging area for about 3 minutes, you will be able to push the tissue back and control bleeding at the same time.  Excellent for working that tissue distal to mandibular 2nd molars on crown preps or deep restorations.  This saved my bacon on a CAD/CAM crown 2 days ago!  You could use another hemostatic agent, but Viscostat Clear is what we use at Eielson.

2. Injecting surrounding gingiva with anesthetic - This was a trick I learned in my AEGD residency and it's saved me more than once.  Here's how it works.  Anesthetic has epinephrine in it to constrict the blood vessels so that the anesthesia stays in the areas we want it to stay.  But this effect of epinephrine can also be utilized to control localized hemorrhaging. Let's say you are prepping a crown on #14 and the mesial marginal area is sub gingival and none of your hemorrhage control methods have worked.  Take some anesthetic and insert the needle directly into the facial side of the papilla between #13 and #14 and inject 1/4 to 1/2 of the carpule with a fair amount of pressure.  This forces epinephrine into the tissue and can keep hemorrhage at bay long enough for you to refine the prep and get a good impression.  The best is to use a high concentration of epinephrine (1:50,000) but traditional anesthetic works well, too (1:100,000).

Note: Do NOT inject straight into the area that is hemorrhaging.  The fact that you're stabbing pissed off gingival tissue will sometimes make it worse.

Prepping crowns:

This is a very stressful procedure for dental students and new dentists.  You're taking away a lot of tooth in hopes that you can reduce a tooth enough for clearance of your material but not so much that compromise resistance and retention.  Here are some tips to help you out!

1. Pick a more aggressive bur - If you pick a moderately coarse or medium grit bur, you're going to notice quickly that you sometimes want to push the bur faster than it will cut.  I've found that using a very aggressive bur allows me to push at a constant rate and get into a "flow", if you will, of prepping instead of constantly feathering off the prep to let the bur speed up again.  If you have an electric handpiece, you may notice that this isn't as relevant, as you can maintain pressure and not worry about stalling out the bur.  However, I like to move quickly but smoothly. I never prep out of control.

2. Prep a wider margin - Another tip from my AEGD.  I don't think I've ever had a case that I said "crap, my margin is about 0.2mm too wide on this one".  A wider margin helps you out in several ways: 1) Easier for you to tell that you actually have adequate margin everywhere 2) easier for lab to discern between gingiva and margin and give you a good product 3) a wider margin gives you some "play" room in case the impression is less than perfect or there's some sort of issue in building the crown all the way out to the margin.  If for some reason you'd need to enameloplasty the margin back after crown cementation, a wide margin gives you room to do this.  Crowns don't fail from having adequate axial thickness. :)

3. Reduce occlusion a little more - In my opinion, you're better off reducing that extra 0.3mm than fighting for the wall height if you can avoid it.  Not to mention, the area we tend to under-reduce is right in the middle of the prep which has no bearing on how tall the surrounding axial walls are.  Get a #330 bur and carve depth grooves into the occlusal table and go down to them.  Then smooth everything up!  Now, this is not a blanket statement condoning negligent over-reduction, but if you're on the fence and are unsure, reduce a little more. This is especially true when prepping for CAD/CAM crowns that will be bonded into place.

4. Change burs only three times/don't prep the same area twice - This is how I prep, and it results in very fast and efficient crown preps without me having to waste my bur trimming tooth structure from two angles.  Here's what I mean.

If you do your occlusal reduction first, you are inevitably reducing the occlusion on areas that will eventually be prepped away when you go to do your axial reduction (example: you reduce the entire occlusion and then end up prepping off the circumferential areas for the axial prep that you just reduced the occlusion on!).  Don't do that!  The axial reduction is virtually independent of occlusal clearance so do your axial reduction first.  I always start "in the open", as I like to call it, on a nice wide area of the tooth that's easy to see. I prep the margin down to the most acceptably apical position depending on the material I'm using.

Let's take a #19 e.max for example (assuming it's ready to prep and doesn't need a core, etc.).  I would start with my aggressive flat ended tapered bur mid-facial ("in the open"... a nice wide area of the tooth) and work my way towards the mesial until I broke through all the way to the ML line angle, keeping the bur as deep into the tooth as necessary to make a complete axial reduction with 1 pass.  Notice how I never switched burs to pass through the inter proximal area?  This touches on two principals: 1) I'm going to prep the interproximal area away anyway so I don't step up with skinny burs, I just push through it with my regular bur 2) prep a wider margin.  So, I work through to the ML angle and then I come back to my starting point mid-facial.  Then I work the same pattern, this time towards the distal until I break through and get to the DL line angle. Then I connect the DL and ML line angles across the lingual.  Margin and axial reduction are done.

Occlusal reduction is next.  Switch burs (first change) to the #330, or a bur of your choice with reference points, and cut the depth groves I mentioned in tip #3.  Now switch back to the first bur again (second change) and level it all out to the depth of the grooves.  Now switch to a fine version of your first bur (third change) and smooth everything.  Done!

The problem with doing the occlusal reduction first is this: You are using false reference points on the outer edges of the occlusal table.  If you reduce the occlusion, you don't yet know exactly which areas you're going to end up prepping off when you do your axial reduction.  So do your axial reduction first so you have your smaller "true" occlusal table, and then reduce it.

Oral surgery:

Caveat: I am not an oral surgeon but I do routinely perform IV sedations and extract impacted wisdom teeth.  I don't do the crazy ones, but I've seen enough to help me become more proficient at taking out all kinds of teeth.

1. Remove more bone - Don't be scared to take some bone away!  Now, this is not a general rule, but it's true most of the time.  On anterior cases, patience is going to serve the patient better than reflecting a flap and buzzing away 4 mm of bone to get that root tip out.  But... for posterior teeth, you should recognize that if the tooth isn't moving now, it's not going to be moving much later.  Do yourself and the patient a favor and remove some more bone on the facial aspect of the tooth and try again.

2. Section the tooth - This can seem scary for a new doc, but sometimes it's what we have to do.  I was recently extracting a severely carious #30 and the tooth kept breaking into pieces while I was trying to get leverage from the mesial.  I had great visualization, so I took the handpiece and sectioned the tooth from F to L across the furcation, broke the tooth in half, and plucked both roots out in less than 20 seconds.

3. Use an endo file - Huh?  Ok, so I've seen this trick before and finally had a chance to try it a few months ago.  A patient had facial trauma and had fractured #7.  The problem is that there was a horizontal root fracture so the root tip was lying a good 3mm apical to the crestal bone.  I got a set of endo files and took the largest file that would engage the root tip at least 1 full clockwise rotation. I wrapped floss around the handle of the endo file and twisted the file to engage the canal of the root tip.  I pulled gently on the floss until, about 3 minutes later, the root tip popped right out. (Notice the clean and unused blade?)

Extracting #7 with an endo file

So that's it for today.  I'll try to catalog some more tips and do some more of these posts from time to time.  Are there any other topics you guys would like my to discuss or give input on?  Just another dentist trying to learn!