Melody Ferzacca

DH 132 Dental Materials

Office Visitation Write-Up

On Friday, May 8, 2015, I visited Tolman Dentistry, the office of Dr. Tolman, in Lebanon. I did
not find out which procedures I would be observing until I was already observing them.
Unfortunately, I was only able to observe the second procedure from start to finish.
Procedure 1 Root canal therapy on bifurcated #5, buccal and lingual, with occlusal
composite filling:
When I came into the treatment room to observe this procedure, Dr. Tolman was
already administering a local anesthetic MSA injection. Dr. Tolman administered 0.75 carpules if
Articaine 4% with epi 1:100,000. Topical Benzocaine 20% had already been administered prior
to the injection.
As we waited for the anesthetic to take effect, I followed Dr. Tolman back to another
patient treatment room where he had already delivered local anesthesia to another patient.
The patient was having two teeth extracted.
I took a short restroom break and returned to the treatment room where I would
observe (as best I could) Dr. Tolman perform a root canal. When I had returned, the rubber
dam and apex locater had already been placed on the patient. He had also verified with the
patient that she was feeling numb.
Using the high speed hand piece with an extra course diamond burr, Dr. Tolman created
an opening in the occlusal surface of the tooth, giving him access to the tooths pulp and canals.
Dr. Tolman then used and endo explorer and an endo file on both the buccal and lingual
roots to find his access opening to the apex of each root. Tami, the dental assistant who was
chairside for this procedure, asked Dr. Tolman what the length was for the canals. Dr. Tolman
responded that they were both 22mm on the buccal and the lingual. Tami wrote these
measurements down on the cassette wrapping paper.
Tami grabbed two syringes containing disinfectant and placed their tips into a device to
bend the long syringe tip so it would reach the base of the pulp canal at the apex in both the
lingual and the buccal. This is why she had asked for the measurements from Dr. Tolman.

After finding where he needed to be with the apices of the tooth, he used the low speed
hand piece with a size 25/.08 rotary file to clean pulp from the buccal and lingual pulp canals
and shape the canals to the size of the file.
While Dr. Tolman was completing getting the patients canals all cleaned out, Tami
mixed a paste-paste sealer, ThermaSeal, for Dr. Tolman to place once the canals were cleaned
out.
Once the patients pulp canals were cleaned out, Tami handed Dr. Tolman a syringe
containing NaOCl, or 50/50 bleach-water mixture to irrigate and disinfect the canals. After
irrigating with the NaOCl, Tami traded Dr. Tolman the empty NaOCl syringe for a new syringe
containing Q-Mix, another disinfectant, to irrigate the canals one last time. Once irrigating and
disinfecting the canals was complete, Dr. Tolman handed Tami back the empty Q-Mix syringe.
Tami opened a pack of paper points. One at a time, Dr. Tolman used endo pliers to grab
a paper point from Tamis left hand and place it in one of the canals to absorb any excess
moisture and liquid from the disinfectants. When he was done with one paper point, he would
place it in Tamis right hand, and grab a new paper point and place it in the opposite canal he
had used the previous paper point in. Tami and Dr. Tolman used two packages of paper points
for this process.
Once the canals were dry, Dr. Tolman selected two gutta percha cones and placed them
in a heating unit. Once heated, they were removed from the heating unit and coated in the
ThermaSeal and placed, one at a time, in the pulp canals of the prepared tooth.
After the gutta percha had been placed and Dr. Tolman felt satisfied with his work, he
removed the rubber dam from the patients mouth and then Tami removed the apex locater.
Dr. Tolman sat the patient upright so Tami could get a maxillary right PA to obtain an image of
the tooth that was just operated on to see how the root canal treatment looked
radiographically. Dr. Tolman and I stepped out of the room while Tami used an XCP and direct
digital sensor to obtain the radiograph. The vertical angulation was slightly off, and the apices
were not visible, so Tami took a second radiograph, in which the apices were visible.
Dr. Tolman said that the material in the canal looked good and that he was going to lay
the patient back again so he could finish the procedure by filling the rest of the coronal portion
of the tooth and occlusal surface.
Tami handed Dr. Tolman a syringe of Porc Etch and Scotch Bond Universal to etch the
surface of the tooth so that the composite could bond. He placed the etchant and handed Tami
back the syringe.
Once the etching was complete, Tami handed Dr. Tolman a syringe of Ceramex super
cure composite material in shade M3. Dr. Tolman placed the composite material and handed
the syringe back to Tami. He then shaped it with a condenser instrument and cured it with a
curing light. Once the composite was cured, he made minor adjustments to the shape and
polished the filling with an extra fine diamond burr using the high speed hand piece.
Tami handed Dr. Tolman a clamp-like device holding articulating paper. Dr. Tolman
placed the articulating paper in the patients mouth and had the patient bite to check their
occlusion after the filling. He made another minor adjustment and tested the patients bite with
the articulating paper again. He asked the patient how their bite felt and the patient said that
for what they could feel with being so numb, it felt fine.

Dr. Tolman sat the patient up and informed them that if any issues occurred after the
anesthetic wore off to give the office a call, but that if everything went as expected, they would
no longer have the pain or discomfort they were having before the procedure. Dr. Tolman said
goodbye and left the room.
Tami gave the patient a print-out of post-procedure information and instructions that
they may feel some tenderness from the procedure but Tylenol or ibuprofen should help and
that if they took some when they got home before the numbing wore off, they would
experience less discomfort. Tami also told the patient that soft foods are not required, but may
be preferred in the event that there is tenderness, but that the patient should not expect
severe pain.
Tami walked the patient to the front of the office with her paperwork and the patient
was dismissed.

Procedure 2 Seating and cementation of #14 and #18 Bruxzir FPC permanent crowns:
The patient was brought back to the treatment room by Tami. She had the patient sit in
the dental chair and remove his mandibular partial prosthetic.
Tami washed the Bruxzir full porcelain permanent crown preparations using a cotton
pellet and Chlorhexidine.
Using a hemostat, Tami removed the temporary crowns that were placed on #14 and
#18 at the patients last appointment. Tami was able to remove #14 with ease, but #18 took a
little more effort and the patient had sensitivity on that tooth as well, prior to removing the
temporary crown. When both crowns were removed, Tami used the panel (in every patient
treatment room) to initiate a beep signal, alerting Dr. Tolman that her and the patient were
ready for him.
After Dr. Tolman arrived and greeted the patient, he placed the permanent crowns in
their appropriate positions, without adhesive. Dr. Tolman then had the patient insert his
mandibular partial prosthetic so he could check the patients occlusion with the crowns in
place. Dr. Tolman was able to reach the clamps with the articulating paper, and placed it in the
patients mouth and had the patient bite together. Dr. Tolman could see that the crown on #18
was too high, and the patient also said it felt too high.
Dr. Tolman removed the crown from #18, and used the high speed hand piece with an
extra fine football diamond burr to file down the base of the crown. He tested the patients
occlusion again, and it was still too high. Dr. Tolman filed the base of the crown down a little
more and had the patient try it again. The patient said it still felt a little high. The third time the
patient said it was close, but not quite right yet. The fourth time Dr. Tolman filed it down and
had the patient bite again, the patient said it was much better and that his bite felt even.
Dr. Tolman had the patient remove his mandibular partial prosthetic, and Dr. Tolman
removed the crowns from the patients mouth.
Dr. Tolman placed Maxcem Elite Cement into the base of the crown for #14, and seated
the crown in its correct position. Next, Dr. Tolman put Maxcem Elite Cement in the base of the
crown for #18, and seated it in its correct position.

After both crowns were seated, the patient sat upright and instructed by Dr. Tolman to
put his mandibular partial prosthetic in and check the bite one last time just to ensure that the
permanent crowns were seated and fit as they were supposed to. The patient said it felt great.
Dr. Tolman said goodbye to the patient and went on to his next procedure. Tami took the
patient to another treatment room where Amanda, the hygienist, was going to finish with the
patient by doing and assessment and completing a prophylaxis for them.
The excess cement after seating of the crowns was not removed by Dr. Tolman as the
patient was scheduled to have a cleaning with this appointment. Amanda told the patient that
she would remove any excess cement from his crowns.

Client Records:
I was unable to see the client records due to a couple reasons. Their office was very
busy the day I went in and the system they use (Dentrix) is extremely fast and user friendly,
which is good for them, but not for me as I couldnt read as they typed. What I got to see on
their records was PARQ and the documentation of the procedures performed. I jotted down
some quick notes, but they are not word for word as they did not have the time to permit me
to do so.
Patient 1 Benzocaine 20% topical administered. Patient was given 0.75 carpules of
Articaine 4% with 1:100,000 epi. RCT #5-B and L (buccal and lingual) cleaned, prepped,
disinfected and filled with gutta percha. Ceramex M3 O (occlusal) filling placed.
Patient 2 Removed temp (temporary crowns) with hemostat. Bruxzir FPC (full
porcelain crown) placed on #14 and #18 with Maxcem Elite Cement.

Infection Control Procedures:

There were no barriers on any instruments or on any other surfaces in the patient
treatment rooms. Instruments such as syringes, or items that had been in or around the
patients mouth were set on counter tops. All disinfection, cleanup between patients, and
sterilization was done by the hygienist or assistants as they used the instruments or the
assistant helping the dentist with a procedure. Aside from their sterilization room being open
and everything in view, I loved their setup. Nothing seemed to get cross contaminated. Their
clean and dirty sides were easy to decipher, even without the designated signs. There were red
light bulbs all around the dirty side, and blue light bulbs all around the clean side. The lights
were above the sinks, cabinets, etc. When I first saw a lack of barriers in the treatment rooms
and things being placed on counters, I didnt think it was very sanitary, but watching them
thoroughly wipe down and disinfect everything that had been touched made me a little more at
ease. I was especially thrown off when the hygienist was using the computer mouth with her
gloves on that had been in a patients mouth. But anytime she went to touch it, she made sure
she had gloves on and made sure that it was wiped down very well. One patient was getting
impressions to get a partial for the opposite arch in which he already had one (I came in at the
tail end of this procedure). The assistant working with him had set his current partial on the
counter while she was taking his impressions. This was one of the very first things I saw and,

compared to how we operate, I was shocked! One thing I did like about how they were set up
was that the patient treatment rooms had cupboards in them. Behind the head of the dental
chair was where the hygienist kept all of her sterile wrapped cassettes and ultrasonic inserts.
She also had patient glasses in a drawer. The saliva ejector was disposable, but the air water
tips were reusable after sterilization and one kept in each cassette. Their method of showing
patients that what was to be used on them was clean was when the cassette was unwrapped, it
was unwrapped on top of where the tray is set up during treatment, and the blue wrapping left
underneath of the cassette. This didnt just show the patient it had just been unwrapped, it also
provided a way for the cassettes and instruments to be transported to the sterilization room
without using bulky trays that dont have enough room for everything on them.

General Impression:
The office is a new office and was built about 4 years ago, so all of their equipment is
brand new. Some of their hand piece units were very interesting looking. After I realized that
their infection protocols werent as scary as they seemed, I was relieved. The dentist, assistants
and hygienist were very friendly to their patients and seemed to make them feel more
comfortable. The patient who had his crowns seated hadnt been to the dentist in 20 years
because he hates the dentist. But he was very friendly to Dr. Tolman and to Tami, as well as
Amanda when she began his assessments and cleaning. I heard her tell him his deposit level
was really low, especially for not having been to a dentist for 20 years.
I have to say, Im glad that they made their patients feel more welcome than they made
me feel. Aside from being introduced to the dentist when I got to the office and goodbye when
I left, the only other thing he said to me while I was there was Have you ever watched a root
canal before? I said I hadnt and it was interesting to see the process (what I could by not
having a view of the patients mouth, only the top of their head). He didnt really say anything
after that. I had my rubric for this assignment with me so they could know what I needed, and
why, but I felt like I was just in the way. I was even sat with the hygienist when I first arrived,
rather than with the dentist. I had to wander around and find the dentist and determine myself
if he was performing a procedure I could observe for this assignment. I had asked Tami about
the client records and she was in a hurry to get them done so she could go to lunch, so I wasnt
able to obtain some of the information I needed, or would have liked to see regardless because
of their system and how they chart their notes. Amanda, the hygienist, graduated from our
program in 2010, so she knew what my assignment was about and that I was there to observe
the dentist. Shes the only one at that office that did not make me feel like I was an
inconvenience. Even the office manager, Ronda, was rude to me when Amanda was telling me
about contractions she was having while cleaning a patients teeth when I was watching her.
She said I was disrupting Amanda, but Amanda told her I wasnt and that she was actually
telling me about contractions and that the staff had been telling her they hoped she went into
labor at work.
Their office is very nice, very clean, and the staff is very friendly to their patients. I
would definitely recommend a patient to their office, but I would not recommend a student go
to their office for an office visit. I had a backup office I could have gone to a few days later, and I
was very close to leaving this office and waiting to go to a different office.