Jenoa Ashcraft

11/13/14
Office Observation Paper
When arriving to the Dr. Chvatals office, I was greeted and given a tour of his office. They have
a lab, a sterilization area, two consultation rooms, and the patient treatment area which included 6
chairs. The tour was pretty brief, as clinic was starting to get going and there was a new patient consult
coming in that they wanted me to observe.
The treatment coordinator brought back a middle school aged girl that came in with her parents
for phase two of her treatment. She was previously in braces, but now needs some further adjustments
as most of her adult teeth have come in. As her mouth has developed, the right side of her maxilla had
developed into a cross bite. The treatment coordinator went over her health history and went over a
questionnaire regarding what concerns the parents and the patient had regarding her teeth. She then
took a panoramic x-ray on the patient and took some headshots to show the relationship of her bite
from different angles. Then, with cheek stretchers, she took extraoral photos of her bite, which was then
transferred to the computer and arranged on a template to document the current state of her teeth and
bite. Doctor Chvatal then came into room and performed an exam to note her overbite, overjet and
angles class, along with some other measurements in regards to his scope of practice. He went over his
findings with the patients parents and explained what treatment would be needed and the reason for
the treatment. He suggested that they start with an expander to stretch the maxilla and palatal bones
to bring the right side out of cross bite. When the maxilla is in the correct relationship with the
mandible, they will put on the braces to realign the teeth. Dr. Chvatal explained that her teeth will
become spaced out as a result of the expander, so braces will be necessary to bring them back into
alignment. He thought it may take about 16-18 months of treatment from start to finish to fix these
issues.
After the consultation, I observed an initial band placement on a woman that was in her midtwenties. The patient was laid back and had on a cheek stretcher with a suction system attached to it to
make sure that her mouth was nice and dry as they were placing the brackets. The assistant appliedan
etching solution to all of the teeth. After letting it sit for the appropriate amount of time, she rinsed off
the etch. She started with the lower right teeth by applying a self etching primer and let it air dry onto

the teeth. She then applied cement onto the back of the brackets and placed one onto each tooth. As
soon as she was done applying the bands to the lower arch, she handed the patient one of the orange
paddles to place over her mouth to prevent the cement from setting up under the white light. She
called Dr. Chvatal over so that he could adjust the bands to exactly where he wanted them. After he
approved, she cured the cement. She then did the same thing with the maxilla, waiting for Dr. Chvatal to
approve the placement of the bands, and then cured the cement. She placed the wire into the brackets
and closed the doors to each bracket around the wire. Dr. Chvatal did a final check of the placement and
wires. After he left, the assistant went over what types of food the patient should avoid and home care
instruction for working around the braces.
In the chair next to the girl who was getting braces put on, a man was getting his braces
removed. The assistant used a bracket remover and popped the braces off of his teeth one at a time. I
noticed that the wire was still in while she was removing the brackets, so I asked about that. She said
that they leave the wire in so that they can pull the wire and brackets as one unit as opposed to having
to take each bracket out one by one. After the brackets were out, the assistant took a slow speed
handpiece with a football diamond bur and took off the cement. She said that they take off as much
cement as they can see, then Doctor comes through and double checks to make sure that they got
everything and fine tunes as needed with a high speed handpiece, and then polishes the teeth. The
assistant then takes impressions to make the retainer. The patient was getting a hard clear plastic
retainer for his maxilla, which they make in office in their dental lab. If a patient was going to get a wired
retainer, they pour up the impressions and place them with a lab slip for their lab person to come pick
up. If they have to send out for the retainer to be made, it usually takes about a week to get back. After
getting the impressions, Dr. Chvatal came back to the patient and placed a three to three retainer. He
used the same etch, prime, bond sequenced that was used to place the orthodontic bands. He showed
me a trick with dental floss to help hold the bar in place while he was placing the cement. He threaded
one side of the floss through 23 and 24 and the other side between 25 and 26 so that it made a c shape
toward his throat. He placed the bar over the pieces of floss in the spot that he intended to place the
bar, then took the ends of the floss and brought it over the bar and rethreaded it through the same
contacts. It reminded me of a little orthodontic bar hammock. By the time he was done bonding the
lower retainer, the patients upper plastic retainer was ready. The assistant showed the patient how to
place it in his mouth and take it back out. She also showed him how to floss behind the bar and
explained the importance of thoroughly cleaning behind the bar.

In a room off to the side of the patient treatment area, Dr. Chvatal had a patient that had
delayed eruption of tooth #11 and # 21. He explained that the tissue is quite thick where the teeth are
trying to come through, much like a callous, which is causing the delay. He performed a procedure
where he takes a laser and removes the tissue that is impeding eruption. The assistant explained that in
addition to helping the teeth erupt, they use the laser to remove high frenum attachment, take down
the lingual frenum in patients that are tongue tied, and recountour gingival margins. She said that
healing time is much faster with the laser as opposed to cutting and suturing, as they have had to do in
the past. The laser cauterizes the blood vessels as it cuts the tissue to prevent bleeding and speed up
recovery. To prepare for this procedure, Dr. Chvatal placed topical anesthetic on the areas he was
treating. He explained that they dont generally require local anesthesia for this procedure, but in some
instances the patient is just too uncomfortable. If the patient is still uncomfortable after topical
anesthesia, he would administer local anesthesia to treat the area. The patient he was treating was
quite sensitive and couldnt handle the sensation, so she would need local anesthesia. As they were
already running over on time for this patients appointment, Dr. Chvatal suggested that they bring the
patient back another time and he will administer local anesthesia to make her more comfortable.
Another patient was in for a progress appointment. It was a quick appointment where they took
the current wire out and Dr. Chvatal checked the progress of the treatment. He then decided that the
patient is ready to move into the next sized wire and altered which teeth he wanted the patient to place
rubber bands. The assistant then placed the new wire into the patients brackets and scheduled the
patient for their next progress appointment. From start to finish, that appointment only took about
twenty minutes, which the assistant said was very common.
I was pleased with the variety of procedures I was able to see. The only thing that I wasnt able
to observe was the use of the iTero machine, which is a 3D scanner that replaces the need for traditional
impressions. It takes a 3D image of the teeth and produces a virtual impression. Using this machine
produces an impression with greater accuracy and better comfort for the patient compared to
traditional impressions. They use these scans when the patient is going through Invisalign. They send the
digital scan to Invisalign and receive the trays within two to three weeks.
At Dr. Chvatals office, he had 5 assistants, one treatment coordinator and a sterilization
technician. The assistants ran most of the appointments. As I have already described, in initial band
placement, they are responsible for putting the bands on the tooth, bonding the cement, and placing
the wires. They also are responsible for removing the brackets and cement when treatment is done. Dr.

Chvatal is responsible for final placement of the bands, final check over band removal, and all treatment
decisions. The treatment coordinator is responsible for running consultation appointments. She reviews
the health history and patients needs. She then gathers the information that the doctor needs to make
a diagnosis, such as taking panoramic radiographs and extraoral photos. After the doctor is done talking
to the patient about what treatment is required, the treatment coordinator goes over the cost of
treatment and payment plans with the patient and then schedules the initial appointment if the patient
decides to go through with treatment. The sterilization technician is responsible for turning over the
units, processing instruments, and any lab work needed, such as pouring up impressions and making
plastic retainers. Dr. Chvatal does not employ a dental hygienist.
Dr. Chvatals office uses Dolphin Imaging and Management Solutions, which is a software
developed by Patterson that is geared toward Orthodontic offices. I was actually quite impressed with
how simple it was to use. The main screen that they kept up when treating patients included the
patients demographics, a profile picture, the dental chart, the most current pano, and the treatment
plan all on one screen. One of the assistants briefly showed me the dental chart, which was geared
toward orthodontic treatment and the different needs they have in regards to charting out proposed
treatment. One aspect of the program that I thought was very helpful was what they call the fish bowl
which is a folder in which there are all sorts of videos on different topics that relate to orthodontics to
help educate the patient. They cover topics such as cross bite, open bite, malocclusion, home care, the
effects of not taking care of their teeth with braces on, and many more topics. I am personally a very
visual learner, so I thought that this was a good tool to use to help educate the patient. I sometimes feel
that I start talking to the patient in dental terms which may fly over their heads, causing them to miss
the point. Being able to see exactly what we are talking about would be very useful.
One of the first things I noticed regarding infection control procedures is the amount of barriers
used. They used significantly less plastic barriers than we do in our clinic. They use a small bag to cover
the headrest portion of the chair, plastic sleeves over the air/water, suctions, and the hand pieces.
When cleaning up the units, they use DisCide and Birex to thoroughly wipe down the units. They used
disposable bite tabs for their panoramic machine, but did not barrier the rest of the machine, but did
make sure to thoroughly wipe down the parts of the machine that come into contact with the patient. I
noticed that during patient treatment, the only time they wore facemasks were during the use of hand
pieces or the laser. The assistants werent wearing masks for initial placement of the brackets or during
progress appointments. Their process in the sterilization room is very similar to ours at Lane. They break

down the trays and place instruments into the ultrasonic machine. They spray the tray with Birex and
allow it to dry completely on a rack before transferring it to the clean side of the sterilization room. They
then take the handpieces and put them into a machine that lubes the hand piece and runs it through,
which takes about 30 seconds and prevents the need to go back to the unit to run the lube through the
handpiece before sterilizing. After it is done processing in that machine, it is placed in a sterilization
pouch and sterilized as normal. They use a Statim autoclave for smaller loose items and a MD11
autoclave for their cassettes. After the instruments are sterilized, she sets up different trays based on
what appointment types they are used in, then places the made up trays in a cabinet on the clean side
of the sterilization room.
In general, even though their infection control procedures seem much more relaxed than the
procedures we follow at Lane, I dont think that they are necessarily being unsafe as they thoroughly
wipe down everything after patient treatment. It does concern me that they dont routinely wear masks
when treating patients. I think Lane does way more to prevent any type of exposure to ourselves or our
patients. I do think that the machine that was used to lube the handpiece without the need of the
dental unit would be a very handy tool at Lane. I know personally when I am on clinic duty, having that
unit would help save me a lot of time. It would remove the need to go to the sterilization room to lube
the hand piece, then back to the unit to run it, and then back to the sterilization room to process it. I feel
like the process of cleaning up all of the units would run much more smoothly with that tool at our
disposal.
A general dentist would refer their patient over to an orthodontist if he or she had
malpositioned teeth or various other problems that could occur in their bite. When I asked the
treatment coordinator about referrals from doctors, she mentioned that a lot of the time it is at the
patients request. They get the majority of their referrals through other patients. They pride themselves
on providing optimal care and thinks it speaks volumes when previous patients send their friends to
their office to receive orthodontic treatment.
I am very impressed with Dr. Chvatals office. It is run very smoothly and efficiently. You can tell
that he takes pride in running a practice based primarily around his patients and their needs. I learned
that he is one of two board certified orthodontists in the Lane County area. This means that he has gone
to the board of dentistry and presented cases that he has seen and answered questions based on the
treatment, as well being given cases seen by other orthodontists and asked what he would have done in
those cases. It is a very prestigious certification. From the consultation appointment that I observed, he

isnt only in the business of making teeth look nice and straight. He finds more importance in making
sure the teeth and in the correct relationship to each other and making sure the function of the teeth is
correct. I find that seeing how well he treats his patients and the quality of care he provides makes me
want to strive to provide the very best care I possibly can for my patients.