Savanna Beddoes

5/9/15
General Practice Office Visit Dr. John J. Johnson
Procedure #1
I went to Dr. Johnsons office in Lewiston, Idaho to observe two separate dental procedures. The
first procedure was the cementation of a permanent crown. The assistant, Rheanda, had prepared
a tray that included what she referred to as a prohpy pack. This included a mirror, an explorer
and a pair of forceps. She also had a tiny dental spatula for mixing, a mixing pad, temporary
crown pliers and the cement (Rely X Luting plus permanent cement).
The patient was welcomed into the office at the front desk and brought back to the room where
myself and Rheanda were stationed. Rheanda had the patient take a seat in the chair, put a bib on
her and asked her how she was doing and if the temporary Iso-form crown that had been placed
two weeks prior had been bothering her at all. She explained to me that the ISO -form material
that was used to create the temporary crown sometimes has the potential to cause irritation to the
gum tissue. The patient advised her that she had not experienced any such discomfort. The
assistant laid the chair back, looked in the patients mouth using a mirror ,advised the patient that
she was just going to remove the temporary crown and then used the temporary crown pliers to
remove the Iso-form crown. The temporary crown had been placed following root canal therapy
that Dr. Johnson had performed on tooth #31 two weeks prior. Rheanda explained that after
therapy, the temporary crown is placed while they wait for the permanent crown to return from a
laboratory in Spokane, which takes about two weeks. The permanent crown for this patient was
a porcelain fused to metal crown. The permanent crown is about 2mm thick on top and 1.5 mm
thick on each side.
After removing the temporary crown, the assistant examined the tissue in that area and cleaned
off all the cement from the temporary crown that was still attached to the remaining portion of
the tooth and the surrounding gingiva. The assistant took hold of the permanent crown and
placed it in the patients mouth, attempting to seat it just temporarily to see how well it fit. She
had some difficulty, and it was at that point that Dr. Johnson entered the room to take a look. He
believed that she might possibly have had it facing the incorrect direction, so took a seat where
she (the assistant) previously was, and had Rheanda move over to a chair on the patients left
side, opposite the doctor.
The doctor asked the patient how she was and again about any sensitivity. He looked in her
mouth with a mirror and then sprayed some air on the tooth to dry off the saliva from the area
with the air water syringe. He explained that he would not be able to do that with a vital tooth.
He then took the temporary crown placing it over the tooth and showing the assistant that she
had had it facing one way but it actually needed to be seated the way that he was now showing
her. He then had the patient occlude and asked her how the permanent crown felt. She replied
that it fit just fine. The doctor removed the crown and handed it to the assistant. The assistant
then mixed together the two liquids to create the cement on a mixing pad with the spatula (Rely
X plus permanent cement). She lined the inside of the permanent crown with the cement mixture
and handed the crown back to the doctor who then seated it in the patients mouth, covering over

the remaining part of tooth #31. The doctor placed a couple 2x2s, stacked on top of each other
on top of the permanent crown and instructed the patient to bite down for 60 seconds. He then
removed his gloves, placed a hand on the patients shoulder, thanked her for coming in and told
her to take care.
The assistant moved back to her original seat on the patients right side, and after 60 seconds
removed the 2x2s. She used an explorer to explore around the tooth and removed the excess
cement. She then took a piece of dental floss and flossed the contact between #30 and #31. The
floss broke so the assistant got another strand and finished flossing. She then explored a little
more, asked the patient again how she thought it fit, then sat her up, took the bib off and walked
the patient back up front to the reception area. Rheanda returned to the dirty room, removed the
tray of dirty instruments and took them back to be sanitized, then removed all barriers and began
to wipe down the room as I was taken into another room to prepare to watch another procedure
there.
Procedure #2
That afternoon I watched a 2nd procedure, again at Dr. Johnsons office. This procedure was for
the preparation and impressions for an onlay. The assistant pulls up the patients chart which
includes actual, colored pictures of the inside of the mouth including teeth and soft tissue. She
shows me where this tooth (#14) was originally an amalgam filling. It was then replaced with a
porcelain filling last August (2014). That filling broke and so the doctor was now replacing it
with an MOLB onlay. The assistant had a counter ready with multiple 3M guns loaded with
different color impression material called GenieBite, a 3 way impression tray, Polyvinyl Aquasil
Ultra, an interproximal carver called a pigtail carver, mouth mirror (2), cotton forceps (3) a set of
burs including a 3-31 to open the tooth,a diamond bur to prep, and a football diamond and flat
diamond to finish the prep, a #8 round bur, a black disc, floss, 2x2s, articulating paper, dycal
catalyst and base, ViscoStat, 2 carpules of Septocaine 4%, Acrylic Integrity, mixing pad,
explorer and flat blade.
The patient arrives at her appointment and is shown back into the room by the receptionist. The
assistant, Sandy, welcomes her, puts a bib on her and reclines the chair. She fills an impression
tray with a blue impression material called Genie Bite. It is dispensed from a 3M gun and serves
as a bite registration. The tray used is the 3 way tray which takes an impression of the arch of
interest, the opposing arch and the bite registration. Sandy has the patient occlude and hold her
bite for about 30 seconds, creating the impression. At this point the doctor comes in and sits
down on a stool to the patients right. He asks her how she is doing and explains to me that an
inlay is much like a designer filling and then an onlay is a step down from a crown. He
explains that an onlay is more work for the dental team but kinder to the patient and to PTS or
preservation of tooth structure. He explains that it is all about drilling away as little of the
structure as possible to preserve the structure of the tooth! He uses a mirror to examine the
inside of the patients mouth. He then administers 2 carpules of septicaine to the maxillary arch
around tooth #14. He leaves, waiting for the area to become numb and the assistant chats with
the patient for a few minutes before the doctor returns. He then explains to the patient what he is
going to do starting with placing a rubber dam to isolate the area and keep debris from being
swallowed. The rubber dam set consists of a rubber dam clamp, pliers, frame and the actual
damn itself. He places the clamp, followed by the damn and frame and flossed the contact

between #13 and #14 as well as #14 and #15. The assistant uses the high speed vac to suction as
the doctor begins to drill. He explains to me that the previous filling is removed by drilling it
out. A 3-31 cutting bur is used to open the tooth and drill out the previous filling. The doctor
finishes drilling, removes the rubber dam, rinses, and suctions out the mouth. He then applies a
yellow gel called ViscoStat. It is an anticoagulant to help stop bleeding. GingiKnit chord soaked
in Styptin is placed into the tooth sulcus to help get a good impression. The assistant now fills an
impression tray with purple impression material from another 3M gun (same brand) to create the
final impression and hands it to the doctor who places it in the patients mouth and has her
occlude for 4 minutes. He sits the patient up, instructs her to stay away from hard, sticky
things and says hell see her back in two weeks, that Sandy will schedule her next appointment
for her. He removes his gloves, places a hand on the patients shoulder, thanks her for coming in
and tells her to take care.
After 4 minutes, Sandy reclines the chair again, pops out the impression tray, and suctions out
the patients mouth. She then fills the #14 spot of the blue impression she had taken with an
acrylic material called Integrity. The assistant pulls out the chord still embedded in the
patients gingival sulcus, and has the patient bite down once again on the impression tray to
create the acrylic temporary crown. She has the patient bite down again for another 60 seconds.
She then pulls the tray out and removes the now shaped and hardened temporary acrylic crown
from the tray (SO cool!). She rinses the patients mouth and explores the area, realizing that she
got a lot of extra material in the impression tray that has is now stuck to the patients gingiva.
Sandy goes about removing all the excess material with an explorer, which takes quite a bit of
time.
She uses a black disc to sweep off excess material from the temporary crown. She explains to
me that acrylic has oil in it so the inside of the crown will need to be ruffed up so that the crown
can properly adhere. Sandy places the temporary crown in the patients mouth and has her close
down. The patient informs Sandy, that she feels like it is hitting a little bit. She attaches the
disc to the slow speed and shaves down the acrylic temporary a little bit. She places it back in
the patients mouth and the patient tells Sandy that it feels better now. Sandy has the patient
bite down and grind on some articulating paper and is satisfied that the patient is occluding
properly.
She advises me that the permanent crown will be created at the lab in Spokane and shaded to the
color specified to match the patients other dentition.. The assistant uses a #8 rounder to give
anatomy to the tooth. She once again places it in the patients mouth and has her bite down. She
removes the temporary crown once again, dries it off and varnishes the outside of it with Quik
Glaze, using a mini brush. She explains to me that she is careful not to get any of the varnish
inside of the crown or else it will not be able to adhere. She hardens the glaze with the bonding
light. She then creates a temporary cement using Dycal. She mixes the base and catalyst
together with a flat blade on a mixing pad. When she is satisfied with the consistency, Sandy
coats the inside of the crown with the temporary cement, places it in the patients mouth and has
her bite down on a small stack of 2x2s for just a few seconds, as the material hardens as soon as
it hits the mouth. She uses an interproximal carver called a Pigtail carver to remove the excess
material.

Sandy then rinses the patients mouth a final time, suctions it, and grabs some floss to floss the
contact areas between #13 and #14 and #14 and #15. She sits the patient up and chats with her
briefly about her son. She then looks at the office schedule on her computer and asks the patient
to come back in in two weeks (Friday, May 8th) so that the doctor can remove the temporary
crown and seat the permanent one that by that time will have returned from Spokane. She
instructs the patient not to chew any gum on that side and to pull the floss all the way through the
contacts. The assistant walks the patient back up front and then returns to explain the charting
process to me, answer any questions of mine, and clean the room. Just like the first procedure,
the assistant is responsible to take instruments back into the sterilization room and load them into
the autoclave, as well as wipe down and re-barrier the operatory.
Client Record #1
Unfortunately, I did not get to observe the documentation involved in this patients charting as I
was instructed into another room. The assistant was pretty busy and I didnt feel that she had
time later to go over this part with me without being an inconvenience to the flow of the office.
The assistant for my second procedure did, however explain their procedure for charting and the
system they use. She also advised me that whenever notes are made to a chart will be audited
within 2 weeks and then made permanent.
Client Record #2
Anesthetics: click on which one you want
Click on tooth
4% Septo
# of carpules: 2
Select crown/bridge
Inlay/onlay
Old restoration: onlay
Select surfaces: mesial, occlusal, lingual, buccal
Click on tooth which shades it
Onlay
Rubber dam
Select tooth shade
Types in notes: original onlay from 6 months ago covering MOLB #14 has been replaced with
an onlay due to fractured porcelain.
Changes to health history go in clinical chart: no changes
Applied treated cord
1 acqusil impression
Tuxatemp cemented with Dycal
Shade C4/3
Verbal instructions given
Next visit: seat onlay on #14 in two weeks (Friday 5/8)
The chart will be audited by another employee within 2 weeks. During that time changes can be
made to it. After it has been audited, no further changes may be made to that entry.
All existing restorations were highlighted in green. Note was made that a premolar on each side
was congenitally missing.

Infection Control Procedures

There was a separate room for sterilization. The assistants all did their own sterilizing of
instruments. They also cleaned their own rooms and re-applied barriers. Each assistant had their
own assigned room as well. For the cementation of the crown the assistant wore gloves and a
mask, but no safety glasses as we are required to do at LCSC. For the preparation of the onlay
the assistant wore gloves, a mask, and just wore her personal eyeglasses. Each room had a pair
of forceps that sat on a clean counter that the assistants would use to open cabinets and such so
they did not need to re-glove during a procedure. After the procedure the counters would be
sterilized and the forceps ran through the autoclave. I thought that was pretty ingenious! Rooms
were cleaned, barriered, and set up for the next patient immediately following chart notes.
General Impression
I was beyond impressed with the kindness and enthusiasm of this particular dental office when it
came to their treatment of each other and of patients. They had great rapport with one another
and often times had the patients cracking up. They made both myself, and the patients feel very
welcomed and at home! The doctor was incredibly personable and made sure to give each
patient that hand on shoulder thank you. He answered all the patients questions in a clear
manner that they could easily understand. When I asked questions, the doctor really took the
time to explain things. He also gave me some tips and advice on picking a dental office to work
in and was incredibly encouraging. Everyone at the office from the receptionist, to the insurance
girl, to the assistant, hygienist and doctor ALL seemed to absolutely love their job, each other,
and their patients. It was incredibly exciting and refreshing to watch people having so much fun
working together. You could tell that this was evident to the patients as well and that they
appreciated the staff there! I would love to do another assignment like this maybe after doing
restorative next term! I found it to be incredibly interesting and so much fun to see done in real
life! Seeing the interaction between the staff members themselves, and between the staff and
patients was incredibly rewarding and thoroughly impressive.