Going to sound strange coming from me but I agree totally with Peter Campbell. The neat thing about being in a three man office is I can have two other eyes look at radiographs and give their opinions. Generally they are more aggressive than me so I'm usually under diagnosed. Much has changed since Guy Moorman graduated from dental school and since David Boag and my partners graduated. Those "etchings" that we now know to be almost always larger than they appear we considered etchings in 1969 and if I have showed up at the board meeting with one of the lesions that my partners searched for I would have not even been able to administer anesthesia and would have flunked. There had to be clear dentinal invasion. That has changed.
Well put, Peter!Best wishes to you, Dave. My toughest challenges turn out to be my best teachers. Remember, "Don't take ANYTHING personally".PFrom: Peter CampbellSent: Friday, February 01, 2013 4:43 PMSubject: RE: [ACEsthetics] Wow! Wow! Wow!--
Hi all,
Interesting case but not unusual.
My take on it….
1) You are in the DIFFICULT SITUATION of being the bearer of bad news and it's UNEXPECTED bad news…so…you have to tread very carefully here. Even if you are 100% right! I will say that again- even if you are 100% right! Does NOT matter – you still need to take a breath and relax as you have discovered the Rabbit Hole of decalcified teeth and no one else has said anything about it. So THINK before you open your mouth and once again, third time, does NOT matter if you are 100% right and everyone else is wrong.
2) Red Flag Warning…girl's father is a "Big Wig Mucky Muck" and "demands" to be treated to "Porsche/Mercedes" level, nothing but the best at all times, needs to be fully informed (even though he can't even understand the information) and has a hair-trigger temper to boot. (In my mind, that's my first indication to get RID of him as a patient, and/or his daughter, but that's only going on in my mind at the time. I prefer not to work with hair-trigger temper assholes, but that's just me…I would find a reason to refer them out. Something. Anything.).
3) Red Flag again: daughter has anorexia…could be fighting a losing battle against the acid and puking here. Harold Shavell and Ron Goldstein put together can't stop the girl from infusing her teeth (and the margins of restorations) with acid all day. Neither can you. So before you dare pick up a swab of topical, this case demands a case consultation and written letter. Because this sounds like it might be the kind of molehill going into a mountain deal and 5 years from now, goes into court. Fourth time I will say it, doesn't matter if you are 100% right and they are 100% wrong. You could still go to court over this just because Dad is an ass, daughter enjoys weight control through regurgitation, and "45" other dentists probably won't support your opinion.
4) Knowing the players in advance, here's what I would have done: do your full set of digital x-rays…AND…take high quality color photos of the occlusals of all 4 quadrants, plus the standard front, left, right shots. Try to use mirrors to show anything like buccal white lines, decalcifications, "dots" or "spots" on the occlusals, red gingival, etc. Document what she is walking in with.
5) You tell the patient "This is tough! I really have to think about this before I tell you what I would do." You dismiss her but reappoint her two weeks down the road for a 30 to 40 min consultation.
6) You go home and write up a treatment plan with options…crowns?...onlays…?direct restorations…?...fluoride trays for home use…?...xylitol…?.."leave as is"….."observes"…."do nothing"….."seek a second opinion". You can provide a best and an acceptable option.
7) Based on depth of interproximal lesions, can this be stretched out or deferred? Decay is like tire treads…tires wear out gradually but sure, sometimes you get a blowout. Teeth decay slowly. Sometimes what appears to be a "definitely do this now" lesion looks exactly the same 2 years later on an x-ray. Sometimes. Not always. It's a matter of diet, enamel hardness, oral hygiene and genetics/luck. So you don't "HAVE" to "do it all" in the next 3 months. You can prioritize urgency by quadrants or whatever.
8) When you have your consultation letter with "Risks and Limitations of Dental Treatment" done, you get the kid and hotheaded Daddy in and present your findings. Be SURE to print out the digital photos at least on half size 8 .5 X 11 inch sheets so the people can see, sort of, what you see. You explain to them that under magnification and a headlight (and here is where I grab the loupes and light hanging around my neck to draw their attention to the fact that I see everything under magnification and a headlight), everything is seen better and more clearly. It's hard to miss.
9) You give it to them straight but kindly but expect SOME pushback as they are hearing all this bad news all at once. They will be mad at you probably for finding "too much"…they will be mad at the last dentist for finding "too little"…they will be mad they didn't see the principal dentist instead of you….they will be mad Obama's rising taxes…oh, Dad will be pissed at everything. Maintain your cool. "My job is to give you the information as I see it. Here is the plan. Here is what I would do, here are all the options as I see them, but YOU get to make the treatment decisions. Fair enough"?
10) Other useful phrases: "Honestly – if these were MY teeth and I had the same conditions – knowing what I know – HERE IS WHAT I WOULD DO…". "Well, it's a lot of dental work, but lemme tell ya…I'm glad we're talking about teeth and not blood vessels in your brain or heart. "Cause no matter how bad it is, we're still only talking teeth, and that's do-able". "I don't have a crystal ball. I don't know when those cavities will get through the enamel, but once they do, they go a lot faster in the dentin. If you have a crystal ball, let me know when that will happen and I will book you an appointment two weeks before."
11) Don't try to "defend" digital x-rays as being more diagnostic. A clever asshole patient might tell you "digital images can be manipulated to show things that aren't there or vice versa". And he would be right. Only talk about the benefit of reduced x-ray exposure. Don't try to tell him your x-rays are better than the other guys. It will backfire.
12) There – you've presented the information. You have a copy. They know now about all the other factors involved. Now they get to do whatever they want. If you do the work, ok, great. If someone else does it and new caries develop a year later, who cares, you are covered. You gave them a consultation letter with risks and limitations and photographs. Let the other guy worry about it. If they want to get all huffy and go to court, let them. They were dumb enough to try to see someone else and ignore what you told them.
13) Remember, unlike cancer, you don't have to shell-shock the patient with all-or-nothing or you die. These are teeth. It's ok in my book, in most instances, to write some up as "observes" and spread treatment out over a year or a year and a bit. Your boss may be under-diagnosing and his attitude is unglamorous and condescending, but he has learned how to handle these types of patients and he's not sweating it. I DON'T SAY HE'S RIGHT….I just say, he knows how to handle it. And remember "do nothing" is an option….a lot of people in fact do nothing anyways and leave everything until it hurts or breaks. But "do nothing" of course has it's own set of risks, doesn't it? Possible pain, breakage, decay, extractions, cosmetic embarrassment, etc. You put the monkey on their backs…not yours.
My two cents.
Peter Campbell
From: acesthetics@googlegroups.com [mailto:acesthetics@googlegroups.com] On Behalf Of David Boag
Sent: February-01-13 1:36 PM
To: ACEsthetics
Subject: [ACEsthetics] Wow! Wow! Wow!
It's been a long time since I had much to complain about with my employer, but I HAVE to share this:
I had a meeting with the boss today, and he shared with me, among other things, that we were gonna be friends for a long time, because he saved my bacon. Not long ago, I saw a young girl as a hygiene recall. Unbeknownst to me, her father is the owner of a locum tenens staffing company (does dental placement too), and he has a BAD temper. His teenage daughter has a history of bulimia nervosa, and she has had more than half of her teeth restored with composite restorations, most of them (not all) being occlusals or OLs. She had been seeing other docs at the office since 2010, and in that time they had done 2 fillings total on her.
Well, we took a new FMX on her using Dexis, her first digital set, and I don't know what the rest of you think, but digital films done with Dexis catch a LOT more than traditional films often do. Well, I saw TEN different ipx lesions from the FMX and the exam. MOST of them were in the enamel only, but were most if not all the way through, just not visibly into the dentin or DEJ line. Most of them were also tough to see, but all of them were definitely visible on at least 2 films.
It's a big problem when a patient has been in the practice a while and then suddenly you diagnose 10 surfaces of caries, especially if you are a "new" dentist either to the practice, the patient, or both. Well, this dad was IRATE! He took a copy of the xrays and supposedly showed it to 45 different dentists who supposedly ALL diagnosed 1 cavity. He was so mad that he told my boss he was reporting me to the board. My boss talked him out of doing that. He is going to restore 2 of them, and as he does so, if the caries is worse than it looks on the films or worse than he anticipates, he's gonna recommend doing the others. But he thinks I overdiagnosed them too.
I asked to see the films. I made the EXACT same calls I did the first time. I showed him the lesions and said, "You see those lesions, right?"
He said, "I do, but I don't make a big deal out of most of them. I don't overreact. I'll watch most of them and do the first two."
To which I replied, stunned, "On a teenage girl with 10 existing posterior restorations and a history of bulimia nervosa? And a total of 10 ipx lesions on the radiographs? You still watch those? You are trying to be nice, because he is a friend of yours. But I would argue that telling them the truth is the nicest thing you could do for a girl like his, and quite honestly, I would rather him not take me before the board, but if he did, I'd be more than happy to defend this one."
It's frustrating to be the one looking at the complete picture and doing what is right and being accused of overtreatment. You can look really bad if you work amongst others who ignore disease, even when they see it! It's also frustrating when doctors see the holes as the problem and not the conditions that CAUSED the holes in the first place. There is a cost to do right.
I'll try to post the FMX when I can so I can get your opinions. Don't have them yet. Sorry for the vent, but that meeting didn't go how I expected.
--David R. Boag, DDS
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Guy W. Moorman
The Swamp
Douglas, Georgia
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