Repair dentistry – stitch in time or supervised neglect?

The patient was a 40-something single mother in the country. She had survived the good times and the bad, during which she attended the same family dentist since her teenage years. She had good rapport with her dentist and had received regular treatment. As a result, she felt that she was in good hands and believed him when he said that ‘all was well for the time being’.

Circumstances change and she moved to the city, soon after which she developed a toothache and contacted a local dentist in her new suburb. Her new dentist diagnosed pain in the same tooth that had been recently restored in the country and on further investigation discovered caries and pulpal involvement. Dressings were placed for sedation on this tooth and other dubious looking lesions. A thorough examination of the whole mouth with radiographs was also recommended.

At the consultation appointment (after the initial investigations), a treatment plan was outlined. This consisted of several restorations, some extractions of compromised teeth, and a number of endodontic therapies with subsequent full coverage as things progressed. A quotation of up to $20,000 was estimated to bring the dentition up to manageable status. That is, on the proviso that the patient maintains excellent home care, regular maintenance and adherence to a long course of dental therapies in specialist and general dental care.

The patient was naturally alarmed by the progress of her dental disease. Not surprisingly, she needed some answers as to why things had, in her mind, deteriorated so rapidly after having had regular dental care all her life.

Investigation of her previous dentist’s records and reports revealed a number of pertinent issues, which became quite confronting for the dentist. This can also serve as quite a lesson in how we treat our patients and what their later perceptions might be.

The dentist’s recollection differed markedly to the patient’s. He mostly saw her in emergency situations because she was a nervous patient to handle. Therefore there were constraints on how much pain relief treatment he could provide in any one appointment, perhaps looking forward to continuing treatment in the future. There were always time constraints because of the patient’s work commitments. The dentist was well aware that he was never on top of total conservation, he was merely putting out spot fires while the forest continued to smolder.

The practice was further limited, in that endodontic, crown and bridgework were regularly referred to a small number of specialists in the rural region. Travel to the city was not an option. He felt that he was doing all he could given the restrictions placed on him for many reasons. The region was unfluoridated, and oral hygiene and diet were varied and questionable.

The dentist in the city now finds that the patient has improved her oral hygiene routine and diet. Plus, since she has been totally compliant with her treatment plan, her dental restoration is now progressing. She has a better appreciation of her dental situation, and has been introduced to treatment modalities which she would not have had access to with her former dentist. She is now well into the total conservative phase of treatment, and beginning to entertain the concepts of ongoing care and prevention.

The matter was ultimately settled for a sum amounting to several thousand dollars.

Key learnings:

  1. Patients being treated over a long period of time are not static in their ideas of how the practice of dentistry should continue on their behalf. The presence of the media, the internet, and the experiences of peer group are all powerful influences that we can never underestimate. We need ongoing professional development –the patient already has it.
  2. Repair of a broken tooth may be prudent in the case of a clean cusp fracture when no caries is involved, occlusion is not compromised, and the future full coverage is described and prescribed for its midterm management.
  3. Circumstances and patient requirements can change, and prescription has to change with them. What may have been adequate in the past may not be acceptable now.
  4. Either we elect to do endodontic treatment properly or not at all. A root canal dressing to relieve pain is fine, but needs to be followed up with a definitive conclusion. A patient will have no appreciation of a treatment done hurriedly or to save a referral, if retreatment has to follow – even years later.
  5. Communication is, as ever, the key to the ongoing practice of dentistry. However, it gathers new meaning as the years go by. A recall appointment should perhaps be now looked upon as the ideal opportunity to discuss ongoing goals in a revised interest in the patient’s needs.
  6. Nothing stands still – neither should we.

 

Dr Geoff Andrews
Community Relations Officer / Professional Consultant
ADAVB Inc.


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