Friday, June 1, 2012

This Patient Walks Into Your Office...

Happy Friday.

I hope things are well. It is June 1st. My oldest son turns 13 today! These are just crazy times for my wife and I. We have a 13-year-old now and we are still chasing around a 2-year-old. And we love every minute of it.

I had a tough new patient exam this week that I want to share with you. This is a paralegal at a downtown law firm. She claims that she has worked hard to get where she is but she is around some high-powered people. She wants to be able to smile or talk to clients without being self-conscious.

The anteriors are decent, but she has major perio problems in the posterior. Basically, most of the upper right molars have to go (I think we could save #3). So we are left with anteriors and one molar; #12 has major decay, and it needs a root canal and a crown. As a Pankey grad, I started thinking we just remove the bad teeth. We have to get her gums back into shape. Surprisingly, she still has bone around the teeth (she has never had her teeth cleaned). Then we do a bit of ortho and move #11 back into place and get her into a solid occlusion. Then veneers across the front and implants in the posterior. In the lower, all the teeth can be saved. We can either do a Precision Partial or put some implants in all the empty spots.

Remember, her chief complaint is that she wants to smile again. Also, this is not a wealthy patient. I know I am not supposed to think about that but, I do. I was educating her on implants she said that would be out of her price range. I had to take a step back. The treatment plan I had in my head was about $25,000-$30,000 just for the upper.

I had to think of another option. She has very ugly teeth (the picture doesn't do them justice). They are very dark. If I only straighten them, they are just straight ugly teeth. Veneers are the only way to improve the look of these teeth. #11 has to be moved or taken out. How do you do that without a lot of money? You can't. Let’s say we didn't do implants on the top and just made them a partial. That is still very expensive. I think about $14,000, and that is just for the top.

I don't know if taking these teeth out is the best thing for this patient. Saving teeth has been something that has been ingrained in my being since I got out of school. This is a hard concept to get my arms around. Sometimes taking teeth out is the best thing. Hmmm. I just don't know.

What if I put two implants up there and then did a denture? It would be about $1,200 to take out all the teeth and $1,800 to make a denture. If she wanted the palate out of the denture, we could put in a couple of implants. We are talking $5,000-$6,000 for a rock-solid result that looks great.

This might be the first time that what the patient needs goes against what I try to do. I want to make the patient happy and healthy. I guess I would be doing this, but without teeth.

And we still haven't talked about the lower. If the lower costs a couple grand more, we are just making this patient's dream more of a burden. You know how that goes. You bring them in for "the consultation," you deliver the $32,000 treatment plan, and they can't run out of your practice fast enough.

I am not saying that we should put our principles aside. I am not saying that saving teeth isn't an awesome precedent to set. But, I think I want this patient to be happy. And if taking her teeth out will let her smile again, then I am going to do it.

What do you think? Let me know.

Have a great weekend.



Anonymous said...

1.If she is very, very, very motivated, do very thorough periodontal treatment, add a month on multivitamins, ensure she knows how to maintain good oral hygiene practices, and wait 4 weeks -it is amazing how resilient some teeth are.
2.Now with the color, bleach only from first premolar to first premolar- explain there will not be a great deal of color change but it may be enough for her to accept (this lady already knows that any treatment will be a compromise to suit her budget). Also heaps minimize sensitivity.
3. Offer her the option of extracting the lateral and placing a fibre reinforced direct resin bridge - again reinforce that it is a compromise.
4. Yes, these are all compromises but it does allow the patient save up for more ideal options. If, however, the patient wants a full upper immediate then so long as she knows of all the possible negatives and you also agree that, upon the presenting evidence, this is a last chance option, then it is not malpractice to provide it.
I have, from time to time, absolutely refused to provide a treatment sought by a patient. I explain that, upon the evidence, I cannot provide the treatment as I feel it would not be in their best interest to do so. The patient is invited to reconsidered after having time to think it over and encouraged to seek a second opinion and do their own research. Some return, some don't.

Lisa Johnson, DDS said...

I agree with your decision. It is difficult to extract teeth that we know can be saved, but at times, I really do believe that it is the best decision for the patient based on ALL the factors involoved. While we are taught never to treatment plan based on economic status or ability to pay, it is a reality that we deal with every day. You presented the best options to the patient, and she declined. You then revised your treatmtent plan to come up with something you and your patient can live with, and while not ideal for you, the dentist, it may very well be ideal for the patient. If she knows the limitations of what this treatment and still choosed it over a more expensive option, I believe she will embrace the end result and you will both be happy.

dentiste holistique said...

I know it's really hard on your part, considering as a professional you also need to take into consideration the expenses that might be tied up with the procedure. But I really admire your decision in making your patient happy no matter how tough the situation maybe.

dentist philadelphia said...

taking time along with real hard work to make a very good article

gatordmd said...

Thank you Philadelphia.

I appreciate your kind words.



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