Friday, January 20, 2012

What Would You Do?

F-R-I-D-A-Y! Oh yeah!!! Hope all of you are having a good week. Pretty good here.

I saw Hangover II last week and I didn't think it was that good. I am in the middle of Super 8. I have to say that I haven't had much time for movie or books, and nothing I have read or seen has been that good. Let me know if you have seen anything good lately. My queue is kind of flat.

I liked Wednesday's blog and that "what would you do?" kind of thing, so I am going to do another one.

Before I forget: I have been asked to be the guest speaker at a study club in Miami (or as my kids would say, “Your-ami”). You know the study clubs where the meeting is in a restaurant and there is a speaker at the front while everyone is eating? I am going to be that guy. I am kind of nervous, but I got myself into this so I might as well jump in with both feet. It is on a Thursday night. I will finish work at 1pm, get in the car, and be there a little early. I’ll eat, speak for 2 hours, sleep, get up and come home.

I think it is a great way for me to practice and get my name out there. Triodent is putting it on, so there is a little pressure for me to perform. They will have their rep there and she will tell corporate if I stinks or not. It is in three weeks and I am freaking out.

Anyway, I have this patient. He is a 70 year old man and a really good patient. I took this x-ray the other day.

Knowing what we talked about the other day, take a look at the distal of #30. Man, this is a tough one. There is a little spot, straight distal. But I know that to do this little thing, I have to blow through the marginal ridge and do a DO. If I wait, there is a chance it would be humungous the next time I take an x-ray. You can see on this x-ray that he isn't very cavity-prone. On this x-ray, all he has is a facial filling on #5. Would you do it? Would you wait? Tell him to up his home care?

Okay, next one. This patient is 7 years old with decay on distal of #F.

On paper, there is no question: do the filling. But looking at the x-ray, the permanent molars are getting close. Her 9-year-old sister is in the other chair getting her teeth cleaned and she has already lost her upper first baby molars. Is that cavity going to be an issue in two years if not done? If it becomes an issue, what is the big deal? Just take it out. We know the permanent tooth is going to be really close. But to do the filling is so easy. Just 0 minutes and she’ll never have to worry about it. But I don't want them to have to pay for something that might not ever be a deal.

Anyone have an opinion? Oh, let me rephrase that (I know you have lots of opinion; I have read all the comments). What do you guys think?

I hope you have a great weekend.



Joe said...

John, for the 70 yr old with Distal Class 5 decay: I've done a good number of these, especially on senior pts or those with with advanced recession. If lesion is dead center Distal I'll anaesthetize with articaine infiltration on buccal plate, go in DB access usually only with slow speed, then isolate with premolar-size sectional matrix fixed with contoured wedge (usually placed from lingual), use Fuji Conditioner and Fuji IX Extra injected from Buccal. Let set 3 minutes, remove wedge and matrix band, contour with finishing carbide and thin finishing strips to get smooth floss check across all margins. 20-30 minutes tops, even with requisite chatting. Generally very good results.

dentist Costa Mesa said...

I was wondering How to distinguish between ridges?Like Triangular ridge, Oblique ridge, cusp ridge, marginal ridge (posterior teeth).

DC said...

Am I going crazy or is #F not visible? Are we talking distal of #S? I would fill it…there's not much dentin between the decay and the pulp. It sounds like you wouldn't be surprised if there's pulpal involvement sooner or later. Why would you let a 7 year old be exposed to dental pain and associate dentistry with pain for the rest her life just to save her parents a few bucks now (because they didn't stay on her about her hygiene and diet as well as they should have)? If you feel bad about the money give them a discount or do it for free and make them the happiest, most loyal patients you'll ever find.

I think I'd take the conservative route on the 70yo, though. Looks like a fairly low risk patient, plus you've got a long time to try to remineralize with fluoride before you'll get pulpal involvement.

David said...

hey John, Good luck with the 70 yr old...I'll stick with kids. I'd fill #S. My rule of thumb is: If it will be there over a year, then it needs to be done. Now if she's not a new patient then you could monitor and retake the bwx in 6 months to check the progression. I battle with this all the time and sometimes it's better to leave it up to the parents. Tell them, "All I can tell you is that I recommend filling this tooth to avoid any pain or infection, but if you would like to monitor it, that's fine with me." I find parents respond well when you put that way. Good Luck, David

Anonymous said...

According to me, the distal of #30 should be filled... of course it's going to be a DO-but you are saving a future endo or maybe even non-restorable root surface decay given he is 70 yr old.

Anonymous said...

I am a little concerned that you might not be recommending tx. based on what you think is in your patient's parents wallet.

Anonymous said...

For the 70 year old, the caries is on the DL so just do the DO and move on. Amalgam would work best here, but I know, it's too cheap. This whole buccal access stuff with magical materials just never seems to work out well.

For the 7 year old, how many times do you want to go back in? The 84 is at the point it needs a DO, but odds are, if you look close, you should do the MOD on the 85 as well. Case closed. In my office if the 4 needs a DO the 5 gets an MO - it always ends up that way in the end whether you do it at the same time or not, so why not do it once. This is 7 years experience in the OR doing kids speaking. G


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