Thursday, July 15, 2010

Last case

Hey all,

I hope you are liking the case presentations. Even though you aren't commenting (which hurts a little), I want to think these things resonate with you. Or I just suck and I am the only one with issues. I am going to have to talk to my therapist about this one. "You are good enough, you are smart enough, and doggone it, people like you."

I have told you that I am interested in getting into lecturing. Well it hasn't been going very well. I have been in contact with a biomaterials professor at the University of Florida. I told him that I would like to come up there and see how things work, and he agreed to let me come to his lab.

This led to me getting interested in the Dental School. I figured that I really don't do anything very productive on Mondays anyway, so maybe I could start working at the dental school on Mondays. I was thinking maybe every other week I could make the drive to Gainesville. I wrote the acting chairman of the Operative Department and told him about my interest. I told him that I would do it for free. He wrote me back yesterday and politely declined my offer. OUCH!!!

So how does a lecturer gain credibility? I can't be a full time faculty because I like what I have. I can't teach more than one day a week because I live 2 hours from the school.

I think I have good stuff but I don't know if that is enough. I have a lot of people have good stuff. I don't know what to do next. I guess I will just keep taking photos and talking to people. Anyone got any ideas?

Okay, last case...

I was a young dentist, about 3 years out of school. I had 4 Pankey Continuums under my belt and I was ready to concur the world. One small problem... I had no patients that needed this kind of work. Maybe I did, but they didn't trust a 28 year old with a $35,000 case.

Well, in this case, this patient was referred to me from my periodontist. He was a brand new periodontist in town. He had just joined the practice that I referred to. This patient went to that office, I mean just walked in. The periodontist that was just sitting around waiting for things to happen gets the walk-ins. Well, this guy turned out to be an awesome patient.

He referred to me a man that was a total mess. He was a guy that had laid cable all his life. He was a hard worker. He had been saving for 10 years and he walked in and knew exactly what he wanted. He wore upper and lower partials and had always hated them. He wanted implants in every spot that didn't have a tooth.

Before I met this patient, the periodontist had already told him what to expect and what he planned to do, they were just looking for a dentist to do it. A full mouth reconstruction... I'm in.

This case started about 12 years ago so I couldn't find the before photos. I found the photos after we started.



I started with temporizing the upper and he kept wearing his lower partial.



The lower was a real issue. He had been missing teeth for so long that he had some pretty wimpy bone on the lower. After some studying, we realized his dream of implants in every spot was not going to be possible. But we were going to do a bunch of them.



The pictures show almost two years into it. The periodontist was young and some of the procedures used were not as widespread they are now. Things took a long time.

So we had implants. And some of them are in terrible spots. I showed you one of the photos with one transfer abutment not in there because the implant was at such an angle that I couldn't put in both transfers at the same time. I ended up taking an impression of the right side, then taking an impression of the front and left. It was crazy stuff.

The implant collar on two of the implants was supra-gingival (and the area was very difficult to work in so we left it). He hadn't done it before and I hadn't done a case this involved before. So we closed our eyes and this is the way the bottom turned out.



Understand that his mouth is so small you do not even come close to seeing the gingival margins. It was amazing I got them in the photo.

I was thrilled. The patient was thrilled. He was so thrilled that he wanted more. What I mean by that is when we finished the color of the teeth didn't match his second molars.

He wanted me to put crowns on the second molars to match his new teeth. I told him it wasn't really necessary. He said, "I have waited a long time to have my teeth looking awesome and when I look back there they don't look awesome." I asked him if I could just prep the occlusal surface and he wasn't having it. So he got what he wanted.


The second photo is in a mirror.


After we were done with the bottom there was this huge sigh. So the periodontist was just going to do some gum recontouring on the upper and we were going to begin on the upper.

While we were in the final stages of treatment on the lower, the periodontist left his group. Remember, he was the third guy in a group that I referred to. The periodontist was not in a different town in a solo practice. This put a bit of a strain in our relationship. See, I was loyal to the group. And he knew that.

So when we were done with the lower, this patient mysteriously called for his records. He was going to go to a dentist closer to the periodontist's new office.
I spent almost four years working with this patient and just as easily as the patient came to me, he left.

I was shocked. I was hurt. My ego took a huge hit. Was it me? Did the periodontist not like my work and implored him to go to another dentist? Was the periodontist trying to start a relationship with another referral source?

You see, crap just happens. I have tried to show you in these cases that some things turn out so good and other things not so good.

If you are a veteran you probably have so many of these stories. Sometimes, you hate the way something turned out but the patient loves the work. These are the people that stay with you and every 6 months you get reminded of how much you hated this case and wish they would move away.

I remember Frank Spear telling the audience that he wished that some of his patients would die because the case was failing so many times, and he is the best there is.

I hope you like talking teeth as much as I do. It is such good therapy for me.

Have a great weekend,
john


6 comments:

Anonymous said...

I don't see why you could not have still worked with the periodontist. Don't you work with more than one specialist?
It does kinda upset me when someone goes some place else. But I just do the best I can and not let people talk me in to doing stuff I will reget later. So when they do leave the next person doesn't what the heck is going on.

People are funny and have a short memory. This pt today says why do I have to pay extra for my periomaintance cleanings when I never used to before. Well before you did not have active gum disease and need to see the periodontist. This person cried poor so I agreed to do the 3mth perio recall till they could get back to the perio for treament. Normally I discharge the pt if they do not get the perio treated. This person forgot they begged me to do this for them a couple years ago and being the soft hearted sucker I agreed to it. Now they forgot and wonder why they have to pay for it. Reminds me not to do any heroic favors for people.

Case looked good. Too bad you did not get to complete it. But just think you did not have to deal with the akward placemnt of implants on the top.

gatordmd said...

Yeah, I didn't have any problems working with another periodontist.
But I think the periodontist felt like this might be a good opportunity to get a better referral source. I don't know.
I figured I did a pretty good job and the three of us were together for a long time.
I don't know what the deal was.
It is a shame.
I am not angry or resentful.
But like you said, It just would have been nice to be able to finish the case.

john

Anonymous said...

I wanted you to know that although I dont always comment, I read and enjoy the blog each day it is posted, as do my associates. Cases like this one, where you work really hard, do good work (you think) and the patient goes elsewhere are hard to deal with ego-wise. This specialist was short-sighted, as you will be less likely to refer to him now. As to the dental school issue, it probably has more to do with politics than expertise. Even world-class engineers might get a turn down if they have no teaching experience. Do you think passing the ABGD might help in that regard? In their explanation of the board exam, they cite teaching credentials as one of the benefits of a board certification in general dentistry......

suzan said...

Your experiences with people dropping off the face of the earth ...without explanation is sadly, all tooooo familiar.

May I offer; I think you hit on an insight.."Sometimes, you hate the way something turned out but the patient loves the work." Or is it that the patient loved who delivered the work and the work mattered just a little less or was good enough. How many times have you seen lousy dentistry and the client raves about the dentist? Is it possible that clients can value the person more than the dentistry? If they think the dentist is no more than a tooth mechanic, are all dentists then not equal? Do patients refer others saying, "man this guy is good you should see his margins"?

I wonder if you compare the exit man to the many I'm sure that stick by you, if in revisiting the quality of the relationships if you won't find they latter might know you better. I mean really known you..what you stand for, your values, your why's behind your what's? There may be some value in considering how that happens in your practice; by serendipity or design. Presumably as a Pankey grad you know of the concepts of which I speak.

I believe and it's been my experience in 30 years that people indeed do go where they feel understood rather than where they are taught to understand.

When one spends as much time, energy and money as you have on clinical mastery it's just that the tooth talk comes naturally...tends to be more about what we do than who we are.

Seems to me that if client and provider don't really "click" (values resonance), we're at risk of getting blind sided with behaviours when we work on strangers don't you think?

It's a cousin to getting compliance rather than adherance.

I hear your passion, commitment and frustration.

"There's more good about you than you know" said Gandalf to Bilbo.

Is it possible Bilbo that there's more good about you than your patients know?

I honour you. (Yes I can spell, it's Canadian eh? ha ha)

Anonymous said...

I truly enjoy your blogs please don't stop.

gatordmd said...

Oh you are too kind.
Thank you.

I plan on doing this blog until I am world famous so....I might be doing this awhile.
But I did just hear I have 10 readers in Australia. So it could be sooner than I thought.

I love writing this blog and the more comments like yours will keep me going for awhile.
john

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