Friday, February 22, 2008

Just when you thought it was slowing down.

What a day, yesterday.

(I tried hard to make this blog visual, and have lots of pictures but my camera and computer are driving my bonkers. You know when you are doing something and it is working and then you try to do it again and it doesn't work. You want to pick up something very valuable and throw it down to the ground and stomp on it. I was able to get two in...I will continue to work on it. Wish me luck. I might be in the market for a new camera and montior soon. Don't forget to double click on the pictures and you will be able to see the detail)

I have had a couple of patients walk in this week that I think I have to tell you about.

First, an 81 year old woman comes into my office for a New Patient Exam. Now when someone is later in life I usually alter my treatment plan so to be as fair as possible. Meaning, I usually will not treatment plan a full mouth reconstruction on someone this late in life. I know all you neigh sayers will disagree, but I treat all mature people like I would want my mother to be treated. I want them to be as comfortable as possible with as little work as possible.
You might say, “Well, you never know she might live to be 100.” There are very healthy 81, you know the ones that still do aerobics and play tennis and then there is the smoking, watch TV with a couple of glasses of wine, 81 (not that I have a problem with smoking and wine). This woman happens to be the latter.
But she had some needs that couldn’t be ignored.
On the top she has 2 and 5-12. #5 and 6 are broken down to the gum line. #10 has a 12mm pocket on the mesial, due to a root fracture. #’s 11 and 12 are abutments to a 3 unit cantilever bridge.
So she has #2, 7, 8, 9, 11 and 12.
I thought about regular partials but she didn’t want any wires showing. Iwill come back to the bottom in a minute.

On lower she has 21-29. 23, 24, 25 and 26 all had deep (apically) caries . Good occlusion, good perio, no TMD.
Money is not an issue.
So I am able to do any type of treatment but remember my philosophy about my mother or in this case my grandmother (well, maybe your grandmother, my grandmother was mean as a snake).

I am NOT going to suggest implants so don’t even think about it. In the discussion appointment her and her husband were saying stuff like, “remember Bob down the street, who had all that work and the next year was in that nursing home?”
So this is what I decided to do.
Remember, this is MY blog. I am up for constructive criticism but not mean spirited jabs.
On the top I decided to remove 5, 6 and 10 then just do a traditional partial. I can get retention on #3 and #13 (which is a cantilever). Now I am going to have an issue with retention on #7. I will put a lingual clasp and hope for the best. I could do some sort of precision attachment but that would involve prepping for a couple of crowns and adding $2600 to the treatment plan.
Now on the lower, I have decided to extract her incisors. Then do crowns on the remaining teeth (21, 22, 27, 28, and 29) connecting them with a hadar bar and then adding ERA attachments on the distals of #21 and #28. So the lower will be real solid. A lot of work but I didn’t think I had much of a choice. If I have to do work I want it to be excellent.
All this to tell you that this little mature lady is going to have $13,000 worth of work.
$13,000, now that is a lot of coin. I keep going over it in my mind. Should I do the ERA's on top. Is that too much work on the lower? I guess that is what conscientious dentist should do. This is how I make myself feel better.
She is starting in a couple of weeks. I will let you know how it goes. I will take lots of pictures. As you can see I am still having trouble figuring out how to put pictures on the blog. Today I got two in and it won't let me do anymore.

Patient #2 is a 66 year old retired physician from Puerto Rico. His family was poor, so as a child he had no dental care. His college roommate became a dentist. So in the middle of his life he had a reconsturction done.
All his teeth are crowns. He has a bride from #2 to #10. Abutments on #2, 4, 6, 8, and 10. #11 is broken off below the gum line.
#4 has through and through decay .
The lower has a bridge from 19-31. Abutments on #20, 22, 23,24,25,26,27, 30 and 31. Get this, the abutments on #30 and 31 are on a huge blade implant .
On the lower he has through and through decay on #27 . He recently had two root canal done on #23 and 24 and they accessed the canals through the INCISAL. So he has these two giant holes on the incisal part of these teeth.
His bite stinks. So because he doesn’t have upper left teeth and he doesn’t occlude on the right he postures end to end.
Wow, let’s marinate on this for a second. Basically he needs another reconstruction Gammichia style.
He is going to need either a new bridge from 2-10 and then he needs implants on 11-14(maybe an implant bridge, so at least 2 implants).
Then he needs to have the lower redone. That is crowns on 20-27. Then implants for teeth #19 and I don’t know what we are going to do with those blade implants. I guess I can use them. Cutting this thing out would be a huge undertaking.
So that is 20 G’s (no not gagillion) without even doing the implants, which he will need at least 3, which is about 10 G’s more.
The problem with this guy is I don’t think he knows it is coming. You know the patients that come in just wanting a cleaning.
Like me at the mechanic. Yesterday, my battery light goes on in my truck. I tell him I have a dead battery. He says do you want the electric systems test for $39. I say, "No, I have a dead battery." So he puts a ridiculously expensive battery in my truck and off I go. It takes a bit but about 2 miles down the road the light comes back on. I am just like my patients.
So this guys comes in and recognizes he has a need but I don’t know if he knows he has a $30,000 need.
I can fix this guy but what is he going to say when I tell him it is going to cost him a Escalade to do it.
He comes in all smiles and leaves in a pool of sweat.
I know he must know that this kind of work takes a long time, because he had it done in the past. But like I said he had it done by his friend, so I am pretty sure it was done at a reduced rate if anything at all.
He is coming back for a discussion appointment in a couple of weeks. I will let you know how it goes.

This was all yesterday. Just when you thought it was slowing down


Anonymous said...

While I very much agree and admire your approach with older patients, I think that it our responsiblity to present all the alternatives and then present our recommendation. The choice of treatment is ultimately the patients. I always remember my 97 year old patient (with no missing teeth) who needed a molar endodontic procedure and threatened to leave the practice if I persisted in recommending an extraction. Once they understand, patients usually can evaluate there needs.

gatordmd said...

I totally agree with you. If you can remember in the blog that she was concerned about doing all this work then not living long enough to warrant the cost. So in the pre-exam interview and the consultation I try to read my patient. In this case there is also a bunch of communication about her concerns and then I give her my recommandations and why I went in a certain direction.
Thanks for the comment.
I try to keep you posted on her treatment.


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