Tuesday, April 27, 2010

Perfection, Well Almost

Hey all,

We all have demons, some of us more than others (i.e., Dr. Crowder), but we all have them.
And mine is perfection.

I think I strive for perfection in everything. So much so that I am not so fun to be around sometimes.
"Honey, yeah the kitchen looks clean, but I think the counters could have a little less smootz on them."
"Kids, I said, clean your room and yes, your drawers are part of your room aren't they?"
Can you see how fun I can be sometimes? A real ball of joy.
I put this s#!@$t on myself, too.
I have this thing about the lawn. I am not happy unless the edge is a perfect line.
And with the pool. If there is one leaf at the bottom I get kind of uneasy.
But when the lawn is edged and when the pool is spotless, I can't wait to come home and see the fruits of my labor.
I have this weird feeling of peace when I see that edge. I get that same peace when I see the counters shiny clean and when I go to put my kid's clean, folded clothes away and their drawers are in order.

And this genetic disorder carries over to my dentistry. I think it is a product of a lot of different things.
First and foremost, it is in my genes. I think my father was highly critical, and it kind of made me try to work harder for his approval (We can blame our parents for everything can't we? Now everyone that hates this about me...don't look at me. Look at my dad.)
Okay, along with all the baggage I bring from my childhood, I go see these gurus and their work is as close to prefect as you can get.

So put these two things together, and it is a deadly combination.
I finished two big cases last week, and you would have thought someone had shot my dog.
I walked around here moping, and I went home moping.
Let me tell you about these cases.
One was my assistant's brother. He lives in Maryland and has had a partial for most of his adult life (about 40 years). He realized that things were not going so well because the teeth that he had were starting to move.
She convinced him to come down and have us take a look.
Well the next thing you know, he is getting four implants. After the four implants were integrated, we were able to take out his partial and remaining teeth and make him a round house temp.
Then for the other upper four implants he needed bone augmentation and sinus lifts on the top.
I will save you the details, but about 14 months after we started, we began the impressions for 3x4 unit bridges on the top and a 5 unit bridge (unit is what we call one tooth) on the lower.
Last week is when we finished the case.
The case was sensational.

He was thrilled beyond belief. I have to tell you that he went through some major stuff and he told my assistant how this week made it all worth it.
And, oh yeah, it was over $50,000. And to hear him say that is was worth it is like music to my ears.
Then why do I feel like I am walking around with a splinter in my foot.
I haven't stopped thinking about that one margin that I thought could be better.
See I don't know if one of the bridges sat down all the way.
It is one of things that has so much going on. When I tried them in, they were tight. A good tight.
I cemented them in with Temporary cement and after all the cement was taken away, you see that this one was a bit shy. The weird thing was the incisal edges lined up.
Then we went to try in the lower bridge and the occlusion was way off.

I sent it back.
When he returned the bite was totally better, but instead of five points of contact there were four.
Since he didn't live here, every time I had to send this thing back to the lab made for another night or two in a hotel.
All this is weighing on me, and it is heavy.
I cemented it in.
Now don't even get me started on the exposed implant on the upper left, and I know he is going to come back to finish the lower left and do his lower anterior but....
I still feel like I am walking with a limp.

The next case.
This guy has never been one to clean his teeth.
He has never been one to come to the dentist regularly either.
But one day he came in, on an emergency (what a surprise), and he had broken #9 (upper front tooth) 2/3rds down the root.
It needed to come out. So this was going to force his hand a bit. He was going to have to do something major.
He said I have $10,000, what can I do?
Oh, before I forget, he has 22-27 on the lower, and he wants a partial for the lower, #22 and #27 were decayed to the gum line.
I agonized over it for a week or two, and this is what we decided.
We were going to do a temporary bridge from 3-14 on the top. I had Glidewell temps made and told him that it would last until he could come up with the funds to finish off the top.
Then we were going to make him caps/ERA on #22 and #27, cement them and then make a precision partial for the bottom.

I prepped the top all in one day. Cemented the upper temps and scheduled to start the bottom.
When he returned in two weeks for the bottom, it looked like he hadn't brushed since we put them in.
To back up, I really laid it on hard how important home care was to the success of the treatment.
I told him that plaque will make this thing fail.
We went ahead and prepped the lower and it was definitely not the most ideal, and I explained this to him.
One the try-in of the crown/ERA, it seems that the temps had come off, and he decided it didn't matter and he didn't come in to have them put back on.
There was plaque all over the already weak teeth.
Do you ever have this patient?
Last week I cemented in the crown/ERAs, and it was a mess. The tissue was so unhealthy. I am mad at myself for his lack of homecare. I continue to reiterate the need for good home care (like a broken record). The crowns went in and the partial went in so smoothly....except for all the blood and stuff.
But the case...it turned out so nice. You know the kind when even the pink acrylic on the partial matches the color of his tissue where you can't see it.

This was one week post-cementation. Please note the crap around the crown/ERAs.

But you know I can't stop thinking about how this guy still, after all we have done, doesn't care about his teeth.
So most of us would say, "I did everything I could for this guy." I talked to him til I was blue in the face about home care. But somehow I take his lack of concern to be my problem.
I blame my father.

This job is tough. There is no doubt about it. I spend 10 years of my career trying to get these kinds of patients. They finally are starting to seek me out, and now I don't know if I can handle it.
And then when you do feel great about it. You feel like the esthetics are good and the occlusion is good. You worry about the case breaking or failing.
So every time you see this patient for a cleaning, you mumbling to yourself, "please don't find decay, please don't find decay."

I have reserved my room at the funny farm in about 10 years. And just for good measure, I went ahead and paid in full for my heart surgery.
I blame my critical father.

Have a great Wednesday.

No comments:


PLEASE NOTE: When commenting on this blog, you are affirming that any and all statements, and parts thereof, that you post on “The Daily Grind” (the blog) are your own.

The statements expressed on this blog to include the bloggers postings do not necessarily reflect the opinions of the Academy of General Dentistry (AGD), nor do they imply endorsement by the AGD.