You Don't Know What You Don't Know By: Scott Bridges, DMD

There has been much discussion on the Dentaltown.com message boards about the limitations and capabilities of new dentists. What should be expected of us? What can we do? What SHOULD we do? Should newbies just hunker down and spend two or three years trying to “increase our speed” or “pay our dues” while referring out all the good stuff? Must novices hear the sermons of dental gods such as Dawson, Pankey, Hornbrook, Jackson, Strupp, and Kois before even considering tackling a large restorative case?

The answer is no. In fact, new dentists should be looking at these cases sooner rather than later.

Let’s agree that most new dentists have decent hand skills, otherwise they could not have passed boards. It’s the other skills new dentists lack. It’s no secret most new dentists lack confidence, but even worse, they lack a working knowledge of modern materials and techniques, not to mention advanced treatment planning and case acceptance skills.

So, how do new dentists learn advanced knowledge and experience fast? STEAL it! Well…actually, borrow it. New dentists simply need to tap the knowledge of those who are more experienced and more confident than they are. This may include the lab, an assistant, but most importantly, a mentor. A mentor can be any experienced dentist, as long as the new dentist is free to ask any question at any time and get an objective response based on experience. A mentor should understand the new dentist’s skill level and be willing to offer assistance when requested. A mentor is not a critic or judge, a mentor is a resource.

After graduation, I wanted to shift into high gear and get moving. I didn’t want to flounder around playing a guessing game on what I needed to learn. So I chose to associate in a modern, progressive practice for at least a year. Since then, I’ve been able to draw on the experience of my mentor and the team, and explore new directions in treatment while concentrating on patient care and technical skills—without the added worries that come with business ownership. When the time comes for me to own a practice, I will be better prepared.

Furthermore, I began seeking out knowledge through online resources such as Dentaltown.com while still in school, just as more and more students are doing today. It was on Dentaltown.com that I first learned of many modern materials and techniques, and I continue to do so today, drawing on the knowledge of over 34,000 dentists and dental professionals around the world.

Does this approach work? Yes it does, and I have proof. These photos are of a large case I began only one month into practice. I graduated in May, started working in June, and began this case in July. I offer this case as an example of the esthetic and functional capabilities of the novice dentist, when combined with the experience and expertise of lab, assistant, and mentor.

This 41-year-old male presented with several problems, including decayed teeth, defective and ugly restorations, recession, gingivitis, calculus, beginning stages of periodontal disease, and missing teeth. His medical history was unremarkable. He had not visited a dentist in more than 15 years, even though his wife had been a dental assistant. His chief complaint was a painful #2, and after he was relieved of pain, he agreed to return for a full examination. After the thorough examination and a discussion of the various treatment options, the patient agreed to a comprehensive treatment plan, including 11 indirect restorations, a 3-unit bridge, five fillings, a root canal, full mouth SRP, and a perio consult.

In his book, Paul Homoly asks: “Isn’t it wonderful when patients say YES?” Well, it was wonderful, until I realized I wasn’t sure where to start! It was time to consult my mentor, which I did in depth. Over the next couple of weeks I formulated my plan to attack this patient’s problems. I became bold and sure of myself, even bragging a little to family members about the “big case” I had.

Then came the big day. Let me tell you, when I walked in that room to start those preps, I was terrified. Then I remembered that my mentor had my back. I took a deep breath and went to work. As the case progressed, my confidence increased; the day we seated the # 6X11 IPS Empress crowns and they dropped right in place, I was on cloud nine. But I must give credit where credit is due: I could not have done this work without Dr. William Walden, my employer and mentor, the excellent Keller Labs of St. Louis, and Sandy Tucker, an experienced assistant. All were invaluable to me in offering advice when needed.

The patient approved a comprehensive treatment plan, beginning with a full mouth Root Debridement Therapy (SRP), an OHI, and a follow-up appointment. A periodontal consult was recommended because of the lack of keratinized tissue at the cervical of #23. The patient chose to be sedated for each appointment. (I had attended the Dental Organization for Conscious Sedation “essentials” course my first week of work and the assistants were trained in DOCS protocol as well.)

Appointment #1: Full mouth SRP.

Appointment #2: (non-sedation) OHI and tissue evaluation.

Appointment #3: #s 2, 3, 5, 13, 14 and 15: RCT #2, old restorations and decay removed, cores placed in #s 2, 3, and 5 using Excite, Bond-Link activator, and Tetric Flow and/or Build-it, then prepped for crowns and temporized with Luxatemp. Occlusal composite restorations were placed #s 13, 14, and 15.

Appointment #4: #s 6, 7, 8, 9, 10, 11: old restorations removed, decay removed, and cores placed in appropriate teeth. Crown margins were left 1mm supragingival on 6-11 because I planned on bonding Empress crowns. Old RCTs in #6 and #7 were asymptomatic and were not retreated. At this time, the provisionals on #s 2, 3 and 5 were removed and a maxillary impression was taken using Splash. A “stick bite” was used to determine the occlusal plane. Since I planned on placing IPS Empress crowns on #s 6-11, stump shades were taken on those teeth and included in the lab Rx. Luxatemp provisionals were then placed.

Appointment #5: Removed all provisionals and cemented all restorations except #3 Eris, which was remade due to my error in lab Rx. The restorations were as follows: #s 6–11 IPS Empress bonded with Variolink, #5 Eris and #2 PFM cemented with Rely-X. Further work done at this appointment included, #24 MFL resin, #29 inlay prep and temp, #31 core/crown prep, and placement of provisionals.

Appointment #6: Prepped 18X21 bridge, removed temps #s 28 and 31, new impression and bite, adjusted occlusion on #s 11 and 7.

Appointment #7: Seated #3 Eris, #31PFM , Empress inlay #28, and 18X21 PFM bridge

Both the patient and his wife are ecstatic with the results. It is important to point out that the patient’s wife played a very important role in treatment planning and case acceptance. The patient is very pleased with his new smile and has been diligent in keeping his three-month recall appointments. He is considering veneers on the remaining lower anteriors (to close diastemas) and upper left premolars, which are rotated. Veneers on the upper left posterior teeth would improve the appearance of the smile. His periodontal consult for #24 is pending, and he will probably require a soft-tissue graft in that area.

This case was a tremendous learning experience and a fantastic confidence builder. It’s a great example of what new dentists are capable of doing when we have the proper resources.

As I see this case in retrospect, I can critique my own work from many angles, and there are many things I would do differently if I began this case today. The difference in the quality of the “before” and “after” photos may be obvious to those who have taken digital photography courses. It demonstrates the learning curve I encountered while doing the case. Likewise, a year from now and each year thereafter, my ideas and techniques will change even more. This is professional growth and it’s a necessary part of every dentist’s career. It has been succinctly stated: “You don’t know what you don’t know”. That may be true, but I’ll bet someone else does.

Scott Bridges, DMD graduated from the University of Louisville School of Dentistry in 2003. He is currently an associate at Paducah Dental Care in Paducah, KY. Dr. Bridges is a member of the Dental Organization for Conscious Sedation, American Academy of Cosmetic Dentistry, the Academy of General Dentistry, and the American Dental Association.