IV. Curriculum

Advanced General Dentistry Course Organization

I. Patients - You are responsible for all phases of patient care.

Necessary documentation for complete cases and case presentations (monthly and end of year case conferences)
1. six basic photographs - intraoral anteriors, right and left posteriors (retracted and unretracted); mandibular and maxillary occlusals; and full face (lips in repose – profile); (photographs only for case presentations)
  1. masticatory system assessment
  2. periodontal chart, plaque index
  3. full mouth radiographs and panoramic
  4. complete verified dental record
  5. medical history updated - blood pressure
  6. consultations if applicable
  7. written treatment plan
  8. mounted study casts
Accept patients from other departments or residents only after going through AGD faculty first.
Type of patients you will be treating:
1. carry over from previous years, there will be a very small amount
2. emergency patients.
3. two multidisciplinary cases
4. “Least experience” areas in which you desire more exposure
5. list of patients who are available on short notice
6. follow-up patients who present interesting clinical situations
7. minor teeth movement cases
8. radiation, infectious disease, and special patients

II. Course Format/Outline

Seminars/Literature Review/Case Conferences (every Monday afternoon 1:00PM to 5:00PM)
1. planning and providing comprehensive multidisciplinary oral health care
2. patient assessment and diagnosis
3. hard and soft tissue surgery
4. periodontal therapy
5. pulpal therapy
6. restoration of teeth
7. replacement of teeth using fixed and removable appliances
8. pediatric dentistry/orthodontics
9. practice management
10. Miscellaneous
  1. obtaining informed consent
  2. promoting oral and systemic health and disease prevention
  3. sedation, pain and anxiety control
  4. treatment of dental and medical emergencies
  5. medical risk assessment
11. Digital Dentistry – Cerec/Iterro
12. Esthetic Dentistry

III. Duties and Responsibilities

Administrative Duties
1. Become proficient with Axium (Dental School’s computer program).
2. Complete accurately filling out all appropriate documentation
3. Portfolio
4. Treatment plans on all patients signed by faculty, resident and patient and entered into Axium.
5. Financial/Insurance forms
6. Assistant evaluations
7. Complete Implant Programs/Order Forms
8. Complete Quality Assessment Audits and chart audits
Miscellaneous Responsibilities
1. The physical upkeep and cleanliness of the clinic spaces is the responsibility of everyone. Each week a resident will be assigned responsibility for the cleanliness of the laboratory. If you see areas needing attention, report them to the dental assistant supervisor. IF YOU MAKE A MESS, ESPECIALLY IN AREAS LIKE THE LABORATORY, YOU ARE RESPONSIBLE FOR THE CLEAN UP.
2. Most laboratory work will be sent to the Restorative Dental Laboratories. All work must be accompanied by a completed laboratory form, signed by an instructor. *Must be signed off by the office manager once financial arrangements have been made. 50% must be paid before work is sent to the lab.

IV. Specialty Coverage (see posted Faculty Coverage Schedule)

Periodontics - specified times/on call
Prosthodontics - specified times/on call
Endodontics - specified times/on call
Orthodontics - on call if needed
Oral Surgery - specified times/on call
All others available on call through AGD staff

V. Critiques and Evaluation By Residents

Critiques by Residents
1. Curriculum Review/Instructor Feedback forms on short courses, lectures and seminars
2. Complete an on-line program critique at the end of the year.
3. Faculty Evaluation by students.
4. Tri-annual critique of program by residents found in the tri-annual Evaluation of Resident.
5. One year post graduation follow-up critique/outcomes assessment (recent resident survey).
6. Exit interview with Dental School administration
  1. quality and relevance of classroom instruction
  2. quality and relevance of seminars
  3. quality and amount of clinical instruction
  4. clinical and laboratory support
  5. staff’s approach
  6. faculty’s approach
Critiques by Faculty
1. Tri-annual evaluation of resident
2. Quality Assessment Audit

VI. Quality Assessment Audit - One mechanism of outcome measurement is to regularly evaluate the degree to which goals and objectives of the Advanced General Dentistry program are being met.

Purpose:
1. To assess the quality of work being performed
2. To verify the timely and sequential delivery of treatment as prescribed by a formal treatment plan developed by residents and faculty.
Mechanism:
1. To be performed at a final appointment, upon completion of treatment of comprehensive care patients and prior to placement into the recall system, or at any time at the discretion of the faculty or request of the resident.
2. At least one faculty member and resident will:
  1. Review chart to insure uniformity of organization and presence of all appropriate forms (chart audit).
  2. Review post-treatment radiographs if indicated.
  3. Completely fill out quality assessment audit sheet and file in portfolio.

Advanced Education in General Dentistry Seminar Format

A general dentistry resident will be appointed by the General Dentistry Faculty to serve as chairperson for each seminar date. The chairperson will be responsible for the over-all conduct of the seminar and for guiding the discussion.
The chairperson, after consultation with the faculty will develop an outline for the discussion. This outline should reflect the desired learning objectives for the seminar.
Mini presentation by chairperson (see Mini Presentation).
The faculty may provide a reading list for the seminar. (Not all seminars are literature based.) Each resident will be responsible for:
1. Reading all assigned materials
2. Abstracting one article assigned by the chairperson and providing copies as required (see Literature Review Abstract Example).
3. Discussing the articles in relation to clinical practice.
All seminars will be evaluated and attendance will be taken.

Abstract Form For Literature Review

(see Literature Review Abstract Example)

Across the top of a piece of standard paper will be: date of seminar, topic, name of resident doing abstract. If more than one page is required this information should be duplicated on other pages and the pages sequentially numbered.
Beneath this information, accurately list the reference in the form approved by the National Library of Medicine.
When appropriate, the body of the abstract will be under the following headings:
1. Statement of the problem
2. Purpose of the study
3. Methods and materials
4. Results
5. Conclusions
6. Comments - personal evaluation:
  1. Are the problem and purpose clearly stated?
  2. Is the subject population appropriate for the study?
  3. Is research methodology reliable and valid?
  4. Does article suggest lines of further research?
  5. Are the conclusions consistent with the materials and methods and results?

University of Maryland A.E.G.D. Treatment Planning Case Presentations

Mini Presentation

WHO:	The chairperson of each seminar will present. The advisor and AGD faculty will serve as instructors.
WHEN:	The first 15 minutes of each seminar will be devoted to mini presentations.
WHAT:	You will be required to present a case (or part of a case) that is directly related to the seminar topic (e.g., endodontics, patient management, medical complications). Photographic slides, radiographs and written materials (e.g., charting) are required as appropriate. Comments from the instructors and other residents will be encouraged.

Example:

A –	this 36 year old Caucasian male reports with pain in tooth number 9 secondary to getting elbowed playing basketball two months ago. medical history – WNL; #9 fractured (show slide), EPT – N.R., radiograph – apical radilucency (show film), periodontal condition – slight bleeding on probing (show slide), remaining condition of teeth – caries (not relevant to this presentation). Acute apical periodontitis; gingivitis
T -	Endodontic therapy tooth #9 (show radiographic series) using local anesthetic, 2% xyclocaine u/1/100,000 epi. Then scale, prophy, OHI by RDH
E –	Patient apprehensive as usual regarding local anesthesia; patient advised that tooth could need crown in future; treatment completed.
N –	6 month recall, then 1 periapical film in 1 year.

The audience will evaluate your management of this part of the case and the adequacy of your endodontic fill as seen radiographically.

Literature Review Abstract Example

February 5, 2004 Dr. Leider

Zadic, D., Chosack, A., and Eidleman, E.: The prognosis of traumatized permanent anterior teeth with fracture of the enamel and dentin. Oral Surg., 47:173-175, Feb. 1979

Problem: diagnosis and treatment of traumatized anterior teeth has not been completely studied.

Purpose: the purpose of this study was to examine the diagnostic and prognostic value of vitality tests in teeth which had suffered fracture of the enamel and dentin without pulp exposure, and to determine the recommended time intervals for follow-up examinations.

Method and Materials: eighty-four children aged 6 to 14 years with 123 traumatized teeth were examined within 10 days after trauma. The tests included vitality tests with ethyl chloride, electric pulp test, percussion, and periapical radiographs. The teeth were examined every week during the first three months, then at three month intervals for two years.

Results: of the 123 teeth examined, 109 gave a positive response to vitality tests, initially. Of these 109 teeth, 71 remained vital through the two years, and 32 remained vital during the one year they were followed. Of the other 6 teeth, three tested non-vital at 3 months and remained non-vital, and the other three became non-vital and showed other signs of pulpal degeneration and underwent root canal therapy at 12 months, 14 months, and 2 years. At the initial exam, 14 teeth did not respond to the vitality tests. Of these, 5 became positive within three months, 7 underwent root canal therapy within 4 months, and 2 teeth at 2 years.

Conclusion:

Most teeth with fractures of the enamel and dentin which were vital immediately after the trauma, remained vital.
Some teeth that test vital initially will develop pathologic changes and should be examined at 3 months, then every 6 months.
If the initial pulpal response is negative the prognosis is unfavorable. Frequent examinations in the first three months are indicated during which time a positive response will be received or more usually root canal therapy will be done.
Root canal therapy is indicated in any tooth which has not regained vitality after 6 months.

Comment: Because this study is a clinical study, I think it has direct application to our own experiences in the clinic. While the prognosis is not always clear-cut, the article does at least give some general guidelines on what to expect.

Planned Seminar Objectives in Each Program Area

(all objectives may not be covered during the course of the year)

Planning and providing comprehensive multidisciplinary oral health care:
1. Construct and judge treatment plans insuring integration of all applicable medical/dental specialties following a total patient approach. Assume responsibility for all phases of dental treatment.
2. Properly request and evaluate consultations to/from physicians and other health care providers.
3. Participate in monthly case conference.
Patient assessment, diagnosis and medical risk assessment:
1. Interview patients and obtain a complete health history.
2. Perform necessary diagnostic procedures and devise a differential diagnosis for oral conditions using clinical presentation, demographic information, historical findings and radiographic, laboratory and physical examination.
3. Arrive at definitive diagnosis when histopathologic findings are correlated with the above.
4. Recognize the oral manifestations of systemic diseases and understand their effect on the oral cavity.
5. Order and interpret the clinical and/or medical laboratory tests necessary in the diagnosis and treatment of oral conditions.
6. Prescribe pharmacological agents properly and understand the mechanism of action and effects of drug interaction.
7. Perform treatment procedures when necessary and refer patients with oral/systemic pathology when indicated.
Hard and soft tissue surgery:
1. Maintain the “CHAIN OF STERILITY” when performing surgery in the dental operatory and the hospital operating room.
2. Discuss the anatomy and physiology of the respiratory, circulatory and nervous systems and their response to various pharmacologic agents used in preoperative medication, conscious sedation, local anesthesia and pain control.
3. Demonstrate the techniques of head and neck examination utilized by the oral surgeon.
4. Monitor respiration and circulation as well as manage the patient’s airway.
5. Perform resuscitative technique and demonstrate proficiency in the early management of medical emergencies in the dental office.
6. Diagnose, treatment plan and manage patients with non-complex surgical problems in such areas as exodontia, biopsy and infection.
7. Discuss basic principles in the management of patients with facial injuries.
Periodontal therapy:
1. Perform a periodontal evaluation on all patients treated.
2. Employ preventive dentistry principles in your personal dental care and in all phases of your dental practice.
3. Supervise auxiliaries in the performance of patient education procedures; prescribe treatment to be rendered by the dental hygienist.
4. Diagnose and treat all but the most complex cases of periodontal disease while applying the principles of preventive dentistry.
5. Diagnose and treat HIV/AIDS associated periodontal abnormalities.
6. Utilize the basic periodontal literature in order to defend your treatment.
Pulpal therapy (endodontics):
1. Diagnose pulpal and periradicular pathosis.
2. Use the principles of sterile technique, chemotherapy, bacteriology and preventive dentistry in endodontic treatment.
3. Treat traumatic, acute and chronic endodontic emergencies.
4. Perform conservative endodontic therapy in uncomplicated and selected complex cases with consideration of patients with infectious diseases.
5. Assist in surgical endodontic therapy when indicated.
6. Choose appropriate endodontic equipment, materials and methods for the clinical situation in which each is indicated.
Restoration of teeth:
1. Determine the clinical situations in which the different restorative materials may be used.
2. Appraise new and established dental materials to determine their usefulness in clinical situations.
3. Perform operative treatment with full consideration of the principles of preventive dentistry and periodontics with consideration of patients with infectious diseases.
4. Appraise teeth preparations and finished restorations from the standpoint of improving technique.
5. Apply the principles of esthetic dentistry to operative procedures.
Replacement of teeth using fixed and removable appliances (prosthodontics):
1. Identify the clinical situations in which fixed or removable prostheses are required.
2. Treat a complex case using a semi-adjustable articulator employing fixed and/or removable prostheses.
3. Teamed with other specialty residents, treat a case using osseointegrated implants.
4. Construct complete dentures for problem cases, i.e., atrophied ridges, Class III jaw relations, minimal interocclusal space, gaggers, etc.
5. Use the science of color and optical illusion to produce esthetic restorations.
6. Perform prosthodontic treatment with full consideration of the principles of preventive dentistry and periodontics with consideration of the special requirements of the infectious disease patient.
7. Evaluate your own laboratory work as a basis for improving your skills and helping others to improve theirs.
8. Appraise the work of dental technicians from the standpoint of improving communications with the laboratory.
9. Evaluate and organize the clinic laboratory to manage cases for high-risk infectious disease patients.
10. Appraise mouth preparations and finished prostheses from the standpoint of improving technique.
11. Occlusion:
  1. Use the technique of masticatory system assessment to determine the features of a patient’s occlusion.
  2. Use occlusal adjustment to improve a patient’s occlusion when specifically indicated.
  3. Determine when each mode of occlusal treatment is indicated.
  4. Diagnose and treat patients with temporomandibular disorders using a multidisciplinary approach.
  5. Illustrate the functions and limitations of the major types of articulators.
Pediatric dentistry/orthodontics:
1. Recognize a developing or established malocclusion.
2. Correct selected malocclusions amenable to treatment by a general dentist.
3. Use selective orthodontics as an adjunct to treatment when indicated.
4. Understand the limitations of orthodontics in general practice, act as a primary diagnostic resource and refer when indicated.
5. Be able to manage pedodontic and orthodontic treatment with full consideration of the principles of preventive dentistry and periodontics with consideration of infectious disease patients.
6. Apply the principles of esthetic dentistry to pedodontic and orthodontic procedures.
Practice management included the following topics:
1. Management of auxiliaries and other office personnel.
2. Quality of management.
3. Principles of peer review
4. Business management and practice development
5. Principles of professional ethics, jurisprudence and risk management (Refer to #14)
6. Alternative health care delivery systems
7. Managed care
8. Obtaining informed consent
Management of Pain and Anxiety
1. Use Nitrous oxide sedation in treatment of patients
2. Understand the concepts of I.V. and I.M. sedation
3. Understand basic concepts of Oral sedation (to exposure level)
4. Understand basic concepts of Pharmacology of conscious sedation
5. Perform Basic Life Support
6. manage pain and anxiety in delivering outpatient care using behavioral and pharmacological modalities beyond local anesthesia.
Promoting Oral and Systemic Health and Disease Prevention:
1. Use the principals of prevention in the everyday practice of general dentistry.
2. Understand current concepts of in oral hygiene and hygiene instruction.
3. Use fluoride and other antimicrobic agents in treatment of patients.
4. Understand the technique for preventive resins and use in practice.
5. Understand and use the PSR recall system.
Miscellaneous:
1. Lead seminar discussions and make formal case presentations at monthly case conferences.
2. Evaluate the content, validity and reliability of journal articles.
3. Establish a reference file of dental literature with consideration of infectious diseases.
4. Make oral presentations before a group.
5. Instruct auxiliaries and other practitioners on the management of infectious disease patients.
6. Evaluate quality assurance programs to continually raise the level of patient care.
7. Utilize performance logic in the delivery of dental care.
8. Evaluate your own intraoral photography as a basis for improving your skills and helping others to improve theirs.
9. Use the computer to improve the quality of dental practice.
10. Evaluate infection control procedures insuring maximum possible sterility in all phases of treatment with emphasis on barrier and sterilization techniques in treating infectious disease patients.
11. Evaluate hazard control procedures insuring maximum possible safety in all phases of treatment.
12. Certify in CPR level C
13. Obtaining informed consent
14. Medical risk assessment
15. Treatment of dental and medical emergencies
Lunch and Learn Seminars
Residents can not make arrangements for Lunch and Learns. Residents can direct the company to contact Ms. Peggy Vaccaro (mvaccaro@umaryland.edu) for instructions on how to arrange for the seminar. It takes three to four weeks to process the request.
Ethics and Professionalism
1. Demonstrate the application of the principles of ethical reasoning, ethical decision making and professional responsibility as they pertain to the academic environment, research, patient care and practice management.

Case Presentation Format

All residents are required to present one fully photo-documented comprehensive case at the end of the year. The cases should be presented in Powerpoint and should include at least three of the following disciplines: oral surgery, endo, perio, operative, fixed prosthodontics, removable prosthodontics or osseointegrated technology.

These cases will be compiled in photographic sequential format to be submitted as a final requirement prior to receiving the certificate for graduation.

The case presentation includes:

Typed Patient History and physical, dental examination, and treatment summary.
(Standard Format)
1 or 2 photos of radiographic examinations (Panorex and periapical surveys).
Preoperative state photos*.
Treatment photos with temporization, surgery, or preparations*.
Final treatment results*.

*Centric occlusal view, maxillary arch view, mandibular arch view, both lateral buccal views, whenever possible.

Copy of the presentation should be submitted on a CD to be kept in the resident’s portfolio.

Advanced Education in General Dentistry Program Curriculum Review/Instructor Feedback Guide

Example of How Objectives Are To Be Entered In The Curriculum Review Form

Evaluation of Root Canal Treatment Seminar Outline

Example of How Objectives Are To Be Entered In The Curriculum Review Form

Dr. El Fayez February 26, 1991

I. Learning Objectives: Each participant should analyze the factors that significantly influence prognosis following root canal therapy, and evaluation of criteria for success.

Describe the consequences of over instrumentation and over filling in root canal therapy.
Identify the clinical practices which contribute to a favorable prognosis.
Defend the criteria for determining success or failure.
Relate clinical and radiographic findings to healing and success.
Explain the conclusion that radiographic interpretation is subjective in nature.

II. Comments/Critique (main points):

Factors that significantly influence prognosis following root canal therapy
1. Endodontic “Triad”.
2. Local factors influencing healing.
3. Systemic factors influencing healing.
Criteria for success
1. Radiographic
2. Clinical
3. Types of regeneration
Factors influencing success or failure
Causes for failure
1. Indications
2. Causes
My criteria for success
1. Absence of pain or swelling
2. Disappearance of a sinus tract
3. No loss of function
4. No evidence of tissue destruction
5. Roentographic evidence of an eliminated or arrested area of rarefaction after a post-treatment interval of 6 months to 2 years.