Molly Robertson

DH 271
12/30/21
Periodontal Specialty Office Observation

The office I chose to go to was Dr. Thomas Mueller in Corvallis. The procedures I got to watch

were an extraction of tooth #32 with a periodontal regeneration of a tooth socket on the distal of #31,

crown lengthening, and soft tissue grafting. Dr. Mueller was very professional and created a relaxed and

calming work environment, not only for his patients but also for his employees. This was a very

interesting and unique experience that I was very excited to experience.

The first procedure that I watched was an extraction of tooth #32 and a periodontal

regeneration of a socket on tooth #31 from a patient in their thirties. Dr. Mueller started out by cracking

some jokes with the patient and then proceeded to give an IA and long buccal with some infiltrations. As

he was about to give each injection, he would take the corner of the cheek and shake it bake and forth

and then tell the patient that they would feel a slight pinch. It was interesting to watch the infiltrations

because it blanched the tissue just like the palatal injections, we gave to each other. According to Dr.

Mueller he liked to give infiltrations so there would be less “heme” as he called it in front of the patient.

He also gave a 1:50,000 ratio of epinephrine to help keep homeostasis of the tissue he was working

with. After the patient was all numbed up, he incised the tissue of tooth #32 interproximal and scalloped

along the gingival margin. Next, he used a variety of instruments until the tooth was fully extracted. He

also reflected the tissue and rotated the tooth lingually as he said that it is extracted easier this way. He

did mention that he normally wouldn’t extract a wisdom tooth from this old of a patient, however it was

only soft tissue impacted and not around the IA nerve, so he felt comfortable to perform this type of

surgery. He showed me an image that he took with their conebeam CT imaging machine they have in

office. It showed all the nerves around the tooth. This way it was insured that he wouldn’t accidently

incise into the nerve. The surgery itself was pretty quick. I was amazed on how easy Dr. Mueller made it
look. The more time intensive part of the surgery was the degranulation and the osseous socket grafting

of tooth #31. Tooth #31 had a periodontal defect on the distal. Dr. Mueller showed me the radiolucency

on the radiograph. It was a 9mm pocket which alerted Dr. Mueller to the defect. First, he used an

intersulcular incision and incised two teeth anterior from the tooth he was doing the socket grafting on.

Next, he started the degranulation of the bone. He took quite an extensive amount of time on this

procedure. Dr. Mueller said he had learned from the past that if he didn’t degranulate completely that

the patient would have to return to his office just to have him do the same procedure again. He said

taking the time and energy to really remove every ounce of the degranulation tissue is worth the effort.

He also mentioned that the degranulation tissue grows much faster than bone. Not only did he

degranulate tooth #31 he also packed it with donor bone, also known as an osseous graft. That was not

at all what I thought it would look like. I pictured a slab of bone being placed in the tooth socket or jaw

of the patient. Instead, it was small particles of bone from a donor. The assistant put the bone particles

into a glass container and mixed it with a chemical stimulator and soaked it for 10 minutes before the

dentist placed it into the patient’s mouth. However, before he placed the cortical bone particles into the

distal of tooth #31, he placed tetracycline on it. He said he placed tetracycline on it to make sure to get

rid of the smear layer. Next, he placed the bone into the pocket with a syringe full of the hydrated

cortical bone. He then packed the bone with a condenser. He said he liked to pack with less rather than

more and said that there was no need to pack pass the gingival margin. After he was done packing the

bone, he placed a membrane that draped over the tooth down inside the gingiva that acted as an

epithelial barrier that would stop the soft tissue from growing faster than the bone. He draped it buccal

lingually. After he was done placing the membrane, he was ready to stitch the site up. He used a gortex

non-resorbable suture. He also referred to this type of reconstruction as a ridge augmentation. When he

was completed with both surgeries, he squirted a syringe of a 30 ml of sterile saline solution on the site

before he placed sutures. He used gortex nonresorbable with tooth #31 too. The whole procedure from
start to finish was 1 hour and 30 minutes. The post op instructions were to not brush the night of, to ice

his cheek throughout the day for 48 hours 20 minutes and 10 minutes off, take ibuprofen every 4-6

hours. Narcotics were offered by prescription, but the patient declined. Swish with chlorhexidine or

warm salt water.

The next procedure I watched was a crown lengthening. He first worked on the crown

lengthening which was for the placement of a future crown. He said he wanted to make sure that there

was enough room for the crown so that the crown would seat correctly. The tooth he was working on

was #31. He used the flap technique like he did previously. I’ll admit it did make me internally squirm,

just imagining myself getting this type of procedure. When I took myself out of the equation, I did much

better. He used a high-speed endcutting bar for the ostectomy to make it have a smooth a continuous

look with no ledges for bacteria to coalesce on. He said it could also be called an osteoplasty which is the

reshaping or recontouring of the bone. He took the bone down quite a bit on the mesial side of the root.

After he was pleased with the ostectomy he than used the saline solution to give it a good rinse before

he placed sutures. This time he used three gut resorbable sutures. This procedure took 1 hour. The post

op instructions were the same for the first procedure.

The last procedure was soft tissue grafting. This was for teeth #23-25. The end goal was to

eliminate the recession of these teeth. To start he first made an incision to remove a flap of tissue that

was at least 2-3 inches across and about 3-4 inches long. He gave the patient a greater palatine injection

with 1:50,000 epi. He used his flapping 12 blade to proceed. He then cauterized the site to prevent

excessive bleeding. After the tissue was cauterized, he placed a palatal shield. Next, he proceeded to

incise the next area to prepare for the soft tissue transplant. He started with the gingiva posterior to

teeth 23-25. Essentially, he cut the gingiva and moved it up so there wasn’t any recession. He then took

the palatal tissue that he incised earlier and placed it below the gingiva he moved superiorly. However,

before he sutured the palatal skin posterior to teeth 23-25, he placed surgical squares to help with the
clotting. He used a compression suture which he said hugged the graft more snuggly. The type of suture

he used was a 5 chromagut dissolvable. This procedure also took 1 hour. The post op instructions were

to ice alternating 20 minutes on and 20 minutes off during the first 24-48 hours, keep head elevated

above the heart, avoid sleeping/laying on the side that surgery was performed, 2 days after surgery

moist heat will help with minor swelling. Do not remove the stint for 24 hours for anything, just swish

with chlorhexidine rinse and lukewarm salt water. Chew on the opposite side your mouth.

The type of instruments that were used was 12 and 15 blade used for flapping, orband used for

pushing papilla, elevators to extract teeth, particularly the wisdom tooth, elevators can loosen teeth

prior to forcep extraction, he used 2 types of elevators, large and small, 36 hoe to clean plaque,

infection and debris, scalers to remove plaque, 4R 4L to remove plaque, spoons (scoop extraction

socket), forceps (pulls teeth) 151 and cow horn, bone pluggers (pack bone), cotton pliers (to open

drawers), high speed endcutting bar for ostectomy, and bite block for patient comfort.

The products used during treatment were saline solution to rinse the surgical site during surgery

and before suture placement, tetracycline for smear layer removal, gortex nonresorbable sutures for the

extraction and socket grafting procedures, 3 gut resorbable for crown lengthening, 5 chromagut

dissolvable for soft tissue graphing, donor bone for socket graft, membrane for epithelial barrier to

promote bone growth over soft tissue growth, and surgicel for clot management and post operative

bleeding.

The type of practice management software used by the front office is Daisy and the software

used by the hygienist and periodontist is panda. Daisy is apparently very similar to the program we use

at LCC clinic. The hygienist said for her the difference from a general dentist office is that she doesn’t

chart decay and spends more time charting recession. Dr. Mueller said he uses his software for writing

letters to patients and to other dentist offices to keep a paper trail for legal reasons. Another difference

in his software is that he can keep pictures from the conebeam CT machine. For the most part he was
very displeased with the program and said he had to make a lot of changes to it to customize it

specifically for his needs.

The role of the periodontist in the practice of general dentistry is working in combination with.

He said that a lot of dentists should be sending more patients over, but they let their egos get into the

way of what is really best for the patient. However, in a perfect world the dentist would work in

combination with the periodontist and vice versa. He also said that he has had patients referred to him

by hygienist who called the patient later that day after their appointment and told them to go the

periodontist. The role of the periodontist to the hygienist should be education, according to Mueller, but

he does not have time to do so but wished he did. His main goal as a periodontist is to treat the patient

and then get them back to general dentistry. He also said his role is to evaluate, diagnose, treat, and

maintain. However, patient compliance, genetics and disease processes can stand in the way.

The rationale for referral of clients from general practice to a periodontist is 6 plus probing

depths, vertical bone loss, mobility (hopefully they come before this happens), and progressing

periodontal disease. The key according to Dr. Mueller is early intervention. These patients are the severe

cases.

The procedures/services typically performed in a periodontal specialty practice is osseous and

pocket therapy, perio regeneration, soft tissue grafting, implants (extraction with bone grafting and

ridge augmentation), sinus augmentation, single unit implants, multi-unit implants and full arch

implants, crown lengthening, implant-supported dentures, and tissue conditioning (scaling and root

planing).

I learned that having a dentist that respects his workers goes a long way. Dr. Mueller was

building his employees up and I could tell that it was a respectful environment. I don’t want to settle for

a job that doesn’t treat me this same way. I also learned that clear and concise communication between

the dentist and the assistants was paramount in a smooth-running procedure. It seemed they could read
each other’s minds. I know they have been working together for quite a while and that has a part in it.

He did mention that when a sub assistant comes in, he’s not the same person. I also learned that the

hygienist gets 1 hour to finish 1 quad and she told me not to accept a job that doesn’t gives me less

time. My overall impression of this practice and office was very positive. When I arrived the front office

assistant was very warm and inviting, the hygienist was nice although busy, so I didn’t get a chance to

pick her brain, the dentist really respected his employees and was very humble. I would love to work for

an office like this. The phone number to Mueller Implants and Periodontics is (541) 757-8330.