An incessant “what happened here?”

complicated system of paths
complicated system of paths

Dentistry is full of variability. Confounders are ubiquitous. Patients are heterogenous; so are their mouths, their diets, oral hygiene habits, and dispositions. Dental materials are marvelous, but they fail. And they especially do when used improperly. And yet materials perform differently in different mouths, and are variably resilient to misuse. Laboratory standardizations are far from replicating the complexity and hostility of the oral environment(s). From afar, dentistry can be seen as a large-scale uncontrolled experiment. This is not to insinuate that Dentistry is not evidence-based. The hierarchy of evidence is a familiar topic in every comprehensive dental curriculum. Cochrane is doctrine. However, and not unlike Medicine, Dentistry can exhibit a disconnect between research and application. You may hear the floor instructor in dental school mutter in discontent something like “I know they teach you that in theory, but in practice, it is often a different story”. And more often than not, the student nods in acquiescence opting to learn the “real life” tips and tricks; altogether bypassing the important debate about why there was the discrepancy between theory and practice in the first place. Those are tangibly interesting conversations to be had.

Imagine if when a patient asked you “how long is this crown going to last doc?” you responded with “Well, reliable human data comes from insurance companies and consequently we typically say insurance companies will cover the same tooth for a crown every 5 years. But lab studies show that in ideal conditions those same crowns can last decades”. That’s almost like saying: “really, the question is how good your insurance is? Or, are you willing to try and match your lifestyle to that of the laboratory conditions? are you willing to consume lukewarm foods and drinks, only stick to food material of reasonable hardness, make sure they have neutral pH and somehow maintain a cooperative oral microbiome?”. I think it may be more fruitful to discuss the reasoning behind why the patient asked that question in the first place. Is it a patient-provider trust issue? Is it a financial and affordability issue? Is it an anxiety issue pertaining to the length or nature of the procedure?? I often start by saying that “it is hard to predict how materials perform in different mouths but we are aiming to do things properly so they last a long time, contingent on you doing your part as well” and following the patient’s lead thereafter making sure all concerns are addressed.

I think these types of reflective questions are important in navigating the complexity of practice. That incessant curiosity about where it went wrong and how that informs our future solutions. And to ask that even when things are going well, because things can change fast. Just like they did for one of my patients. Here is how it went; in retrospect that is.

I have this really courteous, well adjusted, and educated patient. He is one of those you are proud to have in your roster of patients. One you’d ask for expert opinion on topics. One you’d have great conversations with. One whose credentials make you want to try that much harder even if it was a simple filling you were doing. His mannerisms were always professional but never overbearing or demanding. It was a pleasure to look after him. He was new in my practice. His partner recommended us to him. You learn these details and in the back of your mind, logically, you want to keep that sentiment alive, so that the whole household has a good experience. It is not always easy, but it is a reasonable goal to strive for.

I completed his examination. His chronological age matched well with his physiological and dental age. Meaning, he needed the kind of work you would expect to need at that age. You expected his dental IQ to be relatively high. Considering he takes care of his teeth, and having had more complex dental procedures (like crowns and an implant). Aside from the wear and tear that needed routine treatment, he had deep decay in a lower molar that was adjacent to his implant. The patient was only mildly symptomatic describing an odd sensation. But observing him, you might assume he is the type that manages pain well. Navigating those scenarios is often tricky because you know the tooth likely needs more than a filling (i.e. endodontic treatment), but you worry doing the filling will accelerate it. When navigating such ambiguous scenarios it is always important to stage things and gather information along the way. And more so, involving the patient in the decision making process. Even if the patient chose to forfeit their role in decision making, at any stage, it is the responsibility of the practitioner to insure important assumptions are considered. And the possible permutations are interminable and contextually unique. But fundamentals are foundational, and a primer in philosophy and bioethics is prerequisite. It is not just important to know of the social contract, but it is also important to read Jean-Jacques Rousseau. I digress.

“It is my feeling that Time ripens all things; with Time all things are revealed; Time is the father of truth.”

— Francois Rabelais, 16th century French writer and physician

Endodontic treatment was ultimately needed. Time is the great revealer. The tooth was treated, the compromised structure built up and the whole journey protected with a crown restoration and I arranged for his subsequent planned treatment. Unfortunately everything was placed on hiatus while clinics were shut down because of the COVID-19 pandemic for a 3 months period. Imagine the catchup work required after a 3 months pause. A little while after we resumed and at the patient’s delayed 6 months preventive appointment – to my dismay – he came in with the crown in his hand…and the majority of the core build-up in it. I remember it affecting me the whole day. But I also remember mentally planning what the provisional period will look like, and how I will reorganize my schedule that day to fit him in.

Rarely do you get patients who are willfully taking responsibility for their own teeth condition, regardless, I was so bothered by that incident that it prompted me to think about how things proceeded, all the little steps, my notes, checked with my assistant. “Did I skip a step? Did I misuse the material?” We opted to redo the core and the crown after a short provisional period. Upon close examination that day, and as I refined the areas I previously worked on, I gasp as I discover a hint of a crack on the back side where that large decay was. And I started putting it all together in my head. The patient had an implant behind that tooth. Biting on an implant isn’t the same as your own tooth. The “feedback” is different. He had been under a lot of stress and probably clenching a lot. I wondered if the crack was there from the get go. I wondered if this was iatrogenic. I can only say that the clinical exam then did not support such a conclusion. But having looked at it retrospectively, I know what added steps I would want to take to make sure I did everything right from my end. Honoring my end of the contract, so to speak.

homam.alba

I am a general dentist and hospitalist with an expansive interest in education research. I come from a basic science, and immunology research background, and am currently pursuing a master in community health with a health practice education focus.

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