Wednesday, February 24, 2016

Where Do We Go From Here?

Have you ever been at your desk, working up a treatment plan and feeling overwhelmed? I am finding this to be the case more often these days — and in particular, when it comes to a certain patient in need of extensive dental work.

Recently, this patient returned to the office. He hadn’t been receiving comprehensive care for a few years; actually, he was one of those patients who had never really gotten work done. In the interim, he had been in the office to treat a few urgent issues and was reminded each time to return. Most recently, the patient was in with a complaint of a broken tooth. Sadly, as I reviewed the radiograph, I saw much more than what he was noticing. The broken tooth had a poor prognosis, and I had to inform him that I could see multiple other issues and, although he didn’t have pain, they were soon to become apparent. He was quick to tell me he didn’t want to lose any more teeth. I explained to him that he needed to return for a comprehensive review, and that both he and I needed to see the big picture so that we could get him back on track.

It was not long before I saw this patient on my schedule for an exam, but as the radiographs processed, what I saw appearing before me made my stomach drop. I was in shock that the patient was not having more pain. As the images appeared, I began counting the periapical radiolucent lesions. At quick glance, I was already up to five.

Let me tell you, this is a patient for whom I always have had a soft spot. He came to me around 2008, and it had been more than 10 years since he had seen a dentist. He was in bad shape then. He was motivated and ready to begin treatment, as he was getting married. He took advantage of CareCredit, and we began. His was a tough case then, with deep cervical caries throughout. After several months, we had addressed all the decay in his mouth, and he was picture perfect for his wedding. He even stayed on track for a couple of years. In the beginning, a few teeth ended up needing a root canal, which he was compliant to do, but he wouldn’t make that necessary next step to have the crown completed. He understood the need, but financially, he had exhausted CareCredit as an option, and he stated he couldn’t afford the crown and would get it done when he could.

Coming back to the current situation, I completed my exam and noted that the patient had draining fistulas in every quadrant, recurrent caries on nearly every remaining tooth, and multiple nonrestorable teeth. Having gone through the process before, my patient already knew that he was going to need to return for a consultation to review his options and anticipated fees for treatment. The encounter form sat on my desk for days. Each time I pulled up his chart to work up treatment plans, I was at a loss. I thought I finally had learned to plan treatment and block out any preconceived assumptions, but this patient was different. I just kept looking at the radiographs, thinking to myself: How in the world is he going to be able to complete all of the treatment?

Do you often stop and think about how your patient is going to feel while you are treatment planning? How do you keep your emotions from interfering with your treatment options? With time and experience, I have gotten better about controlling those feelings that creep in, yet they are always in the back of my mind. I am, by nature, a sympathetic and caring person, and obviously, I still struggle to get past the emotional side and flip the switch to provider.

The patient was overwhelmed and wants to do everything he can to save all that he can. Sadly, and not surprisingly, he is going to have sacrifice a few teeth in order to move forward. I will do everything I can to give him only the best and get him back on the track to oral health.

Colleen B. DeLacy, DDS, FAGD


Anonymous said...

Sad to say, but the motto for these patients is, "you make your bed, you sleep in it." These people have to accept responsibility for their neglect and their years of poor home care. Often times, with these types of patients, when money is truly an issue, start extracting, go into a transitional partial, and tell them they're on track to end up with a full denture. In the end, perhaps that's the best way to go for some.

Jon said...

This is common and I have one comment for the dental insurance industry to get rid of yearly maximums and get some people healthy. At least let the yearly accumulate for 5 year plans.
Also I have done Stainless Steel Crowns on adult teeth, they aren't perfect, but these protect the posterior teeth. They keep the RCT tooth from breaking.
I have patients who accept this in the premolar region too.
Jon H

Unknown said...

Nice article, Colleen!!!!! A common situation, and frustration, that we all encounter. I had a professor who said, "never care more about a patient's teeth than they care, themselves." It's frustrating to rehabilitate someone's mouth, only to find them back with recurrent decay (despite your best educational efforts). What's also frustrating is the phenomenal cost that some must face when restoring their mouths. With the ever-increasing cost of living, student debt, etc., sometime we are faced with difficult decisions and priorities!!!

Radhika Wadhwa said...

Nice blog which explain the actual life of dentist. How dentist manage the clinic and time management of handling patients.

Jordan said...

Some excellent points here. Sometimes things get much, much bigger than you initially thought they'd be. It's important to learn to take those punches and work through the overwhelming times.

Lassensurf said...

Gonna make some assumptions of xerostomia going on. Medication induced? Any history of taking anti-depressants, sleep meds, or anxiety medications? These seem to be the worst culprits. When I see people struggling to keep up with their dental care and keep existing work for more than a few years that's my first assumption (unless their hygiene is completely neglectful). When they tell me, "Yes" regarding those kinds of meds or when I make the connection for them regarding their dry mouth and trouble with their teeth, it's like they have a revalatory moment and you can often see the determination (or sometimes despair) set in. It's still tricky getting them affordable work, but they understand it all now and can work on the cause and keep it from getting worse.

Great article. I feel for you, and the patient. I never try to ignore or push down those feelings, but there have to be boundaries to them. I can be empathetic while being the responsible professional there to help them. It's their challenge to overcome, I'm just here to help.

Children's Dental World said...

this is a great and useful blog!


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