The Following Dental Patient Cases are real, from my Practice and Personal Experience.
Case 1: Unaddressed periodontal disease and no understanding of cause of needed fillings.
Case 2: Missing teeth with roots still there – saved some money to restore, but requires an imaginative dentist to satisfy patient
Case 3: Crown fell of because not well done in the first place – new dentist used adhesive technology to replace instead of making new crown.
Case 4: Upper front teeth chipping edges – her dentist makes very expensive and unwise recommendation.
Case 5: Fourteen year old boy is extremely afraid of going to the dental office.
Bottom Line for Case Presentations
1. Older woman with esthetic concerns, periodontal disease and lesions not involving decay.
The elegant and well-dressed woman sat uncomfortably in the dental office patient’s chair. She must have been in her early to middle 60’s, but seemed to look a great deal younger. When she spoke her teeth showed straight and white in a face highlighted with animation, but there was obviously something disturbing her equanimity.
“So what you are saying, Doctor, is that the last dentist I went to messed up my mouth”, she said, trying to keep any agitation out of her voice.
On the other side of the desk the dentist, dressed professionally in crisp striped shirt, tie and white consultation jacket, replied; “I would not say that. There was certainly nothing intentional, but it often happens that when seeing a familiar patient over a period of ten or twenty years, some things get overlooked. A dentist can come to think of a patient as having great teeth, and not see beyond to what can only be detected by an extremely thorough examination. In your case your old dentist, being also part of an older educational generation, may not have been as sensitized to some of the problems with gum disease that more recent graduates are.”
Does your dentist pay enough attention to your more subtle needs?
“But I think I’ve taken good care of my teeth. I bush twice a day and have for years. I watch my diet and stay away from soft drinks. Does this have anything to do with gum disease?”, she asked.
“Possibly not. Certainly you show little sign of decay on the crowns of your teeth, where the enamel covers. Other than the very conservative fillings that you had done when you were younger, your decay history is very mild. The crowns that you have were placed largely due to breakage of tooth structure after certain areas were worn flat and weakened with cracks. Good hygiene at home keeps common decay processes at bay. However, you are now encountering decay in areas of your teeth not protected by the enamel, AND lesions that need to be restored that are not caused by decay, but by grinding and clenching your teeth.. These involve areas that were never meant to be exposed to the elements.”
“Still”, she replied, “How could this happen so subtly and now end up costing me thousands of dollars?”
It was clear that the woman wanted to know as much about her condition as he could tell her. She had always been proud of her smile and of her teeth which always attracted admiring comments from friends and suitors. Being widowed 5 years ago and maintaining a very active social life, her appearance had been of great consequence. Yet now, she was finding out that she did not have a major aspect of her appearance under control, that her mouth was unhealthy and she didn’t even know it!
Should she seek a second opinion?
Her only recourse now seemed to be to try to understand the explanations of this obviously caring dentist, but whom she had known for only a short time. She came to him after moving into the area and receiving a mailer from his office. He described himself as a professor at a dental school in the area and a practitioner who cares about teaching patients about their mouth. Could she trust him? Should she seek a second opinion and subject herself to the possible attempts of another dentist to “win her over” to his practice? She trusted her old dentist for 20 years and yet he left her in a difficult position.
“The problems you are facing weren’t all that well known even thirty years ago.”, the dentist said. “Periodontal disease can be mild and still lead to recession over the decades, and as soon as the root is exposed even a little, it is much more susceptible to decay at the edge where the enamel stops. And, the notches on the outside surfaces of many of your teeth at the gum line were for decades thought to be due to excessive tooth bushing.”
“Your previous dentist may well have told you to use a softer brush. Now we know that these eroded areas are due to excessive forces applied to the teeth in sideways grinding movement.”
Her dentist elaborated: “The teeth actually BEND, and the material breaks down there and makes a notch. They need to be filled if they are deep enough to threaten the pulp or significantly weaken the tooth, if they are sensitive or they are esthetically not pleasing. In your case they are not sensitive, but they are becoming noticeable in your smile, and deep enough in several instances where they should be filled to prevent further damage. And a night guard can be worn to prevent more problems that come from grinding your teeth.”
Sensing the truth of what you are told.
“Thank you, Doctor, for taking the time to explain this further. So, basically, as my gums recede I am getting some decay on the roots of my teeth, and as I grind the teeth there are notches forming on the outsides of the teeth that need fillings as well. I understand that more specific cleaning techniques at home can be of help, including flossing the plaque away from the areas of root decay, and possibly some form of intervention to keep my grinding from doing more damage. It all makes sense, even if it comes as a surprise!”
2. Teeth missing but roots intact – and very limited finances.
This middle aged patient comes to the office because she has two spaces on the upper left where the two premolars should be. The gap is not appealing, and she has gotten to the point where she doesn’t want it to be visible anymore. She has saved her money to the point where she has $500 cash, and is hoping there is something I can do for that price.
Can the dentist design a treatment plan that fits the budget?
The roots of the two teeth are still intact, but end abruptly at the gumline – it is just the part of the teeth that would be visible in the mouth that are missing. HOW this came about is hard to know for sure, but with some people addiction to methamphetamine can lead to this loss of crowns, while the roots remain. With her the two roots are healthy – the parts that show at the gumline are solid and smooth. From the X-rays, the roots extend the normal distance into the bone, and are well supported by bone.
Other important information is that there are problems on the adjacent teeth. The first molar has a restoration on the side of the space that needs to be replaced. The canine has decay on the side toward the space and needs to be restored.
See Chapter VI.2 for a more general discussion of alternative treatment plans!
First plan. Remove the roots and place implants. Build crowns on the implants. Restore the adjacent teeth at some point. Gap will remain visible while the implants are integrating into the bone – which will be for a few months minimum. Cost: per tooth from $2000 to $5000. Total cost of treatment approximately $7000.
Second plan. Save the roots, but remove the pulp by root canal therapy and use the canal space to build up the tooth to support crowns. Typical root canal $1500, buildup $500, Crown $1500 per tooth – cost $7000 without the adjacent teeth being restored.
Both of these treatment plans are very acceptable, except for the cost! The costs are totally out of her range, while they both represent good, sound and reliable treatments that, if done well, should last her many years.
But, what can be done that she can afford? I often ask my students to ponder this question and see what they come up with. Obviously, the patient will not go for either of the above options.
Third plan: removable appliance. A cast metal removable partial denture can replace the teeth, and sit on the roots, but be supported by other teeth, and retained by clasping to other teeth. It is a long-term solution, but for a patient not used to removable appliances, takes some getting used to. It covers part of the palate so the tongue can’t go where it normally does, and food items can get stuck under it. It must be removed at night, revealing that the gaps are still there. And, because of the coverage of the remaining roots, they may more likely succumb to decay in the future. The roots can be removed first at minimal cost, but are not available for possible use later. Cost: $1000 to $2000 – closer to her range.
Fourth plan: Flipper. This is a thin plastic removable appliance that includes a false tooth, or in this case teeth, and is hooked onto other teeth. It is not made to last a long time, and is normally worn while a cast-metal framework partial denture, as priced above, is being made. It is breakable, and still takes up space in the mouth that is not comfortable for most people at the start, and compromises periodontal health if oral home hygiene is not the best. Cost: around $500. This would be a possibility, IF she is willing to deal with its insertion and removal, and the unfamiliarity, and the need for periodic replacement. The two adjacent restorations will add to this cost, maybe double it.
Fifth plan: Rebuilding the teeth using composite resin – a “bonding” procedure. For the dentist there is little cost – no laboratory procedures are required, so no lab fee that he has to pay. For this reason, pricing is much more flexible. He can restore the adjacent teeth at the same time. As the teeth are built up, they are connected to the roots using both adhesive techniques AND metal pins (like screws) that are placed in the roots at the corners. The two teeth that are built up will be connected together, so they will support each other under the load of biting forces, AND will be connected to the adjacent teeth, which are being restored, for additional support. FEW dentists have ever done anything like this, but it is certainly possible with our available technology. Longevity is a question, but one would encourage the patient to save her money over a few year period of time while this composite restoration is serving her purposes. Cost: whatever the dentist wants to charge, depending on the time required to do the work. If he values his time at $250 per hour and it takes two hours, then he can do it within the patient’s budget.
This was an actual case in my office, and I did plan 5 for the $500 she had in hand and I guaranteed the work for one year. The ultimate longevity of the restoration was never determined in that the patient was not a regular patient after that, but at least a few years or more would be expected with some caution on the patient’s part.
3. Crown fell off but little tooth structure left to hold it on – and very limited finances.
This patient comes to the office with a gold crown in her hand, stating it has fallen off her tooth and she would like it recemented. She has brought $50 to pay for the service. Upon inspection it is noticed that the crown is almost completely filled with amalgam. Upon looking in the mouth, it is clear that what is left of the tooth that the crown is supposed to be retained on, is quite short – no more than 1 mm tall anywhere around the periphery of the tooth preparation. Simply recementing in the normal way would not suffice.
WHY is the crown filled with amalgam? The previous dentist had attempted to build up a short tooth to a height capable of supporting a crown by using amalgam. The way the amalgam is attached to the remains of the tooth, of course, determines how well it can retain the crown without itself falling off. Clearly, it was not connected to the tooth well enough, and fell off the tooth, taking the crown with it.
When the previous dentist does it wrong ….
The original amalgam buildup SHOULD have been connected to the remaining tooth structure with retentive pins (the screws referred to in the last case). The dentist seemed to think that he could adhesively bond the amalgam to the tooth – and at one point that was common, if just hopeful, thinking. Clearly, it was not adequately bonded in this case.
First Plan: do a root canal on what is left of the tooth, place a post in the canal space, and build up the tooth with some material that will support a NEW crown, that is made to fit the new buildup. Cost: molar root canal $1500, post and core buildup $500, new crown $1500 – total cost $3500. Somewhat in excess of her $50. This is what 90% of all practicing dentists would do in this case, and the rest would extract the tooth and do an implant and crown, for $4000. But, where is this money to come from?
Second plan: recement the crown with the full adhesive technology that is available to us – cutting no corners at all. The amalgam is removed, the gold cleaned up and electroplated with TIN. The tin oxide layer that is formed inside the gold crown is treated with a special chemical that links inorganic materials to organic materials. The tooth is etched and primed with a substance that ensures a bond to the tooth, and then the crown is cemented using a composite (plastic) cement that fills the crown and connects to both the treated gold and the remaining tooth structure. There are no expenses that the dentist has to cover, so he can do this for $50 if he wants. Considering this is a real example from 20 years ago, maybe $100 would be appropriate now. It was guaranteed to last a year, and the patient was encouraged to save her money if the bond failed at some point. Over a year later the tooth developed symptoms and a root canal was necessary, but done THROUGH the crown, which stayed in place admirably throughout the procedure. After the root canal a mechanical connection between the tooth and crown was effected, in addition to the adhesive bond.
The patient saved money in the long run, and the expense of the root canal was averaged out over a period of years.
4. Patient has top front teeth chipping away, giving a poor appearance, indicative of stress. Patient is a business consultant nationwide. No limitation to finances.
This example is taken from a consult that I did a couple of years ago, but illustrates some important considerations.
The edges of the patients top teeth look like saw-blades – ragged and jagged. Her dentist told her that he could NOT polish away the irregular enamel, but would have to rebuild the edges with composite.
Observation shows that the edges are breaking because the lower teeth are wearing away the upper teeth near these edges, and the residual thin layer of enamel is simply breaking away. Another useful piece of information is that the patient reports that this started happening 8 – 10 years ago, and at the same time the spaces that she had had between the front teeth all her life, disappeared. She was happy that the spaces were gone, but not happy about the roughness.
Since her dentist wants to rebuild these edges, BUT the lower teeth are wearing into the space where the composite would go if he simply built them back up, the lower teeth would hit the composite, and she could not close her mouth completely into the normal bite. This is not satisfactory.
The dentist makes a self-serving recommendation!
Her dentist suggested moving all of the upper teeth outward, toward the lip and away from the lower teeth by tipping them with Invisalign treatment. This is an orthodontic treatment using plastic splints rather than brackets and wires. The cost of Invisalign can run $3500 to $6000 and she can afford it. The problem is that if he tips the teeth outward, forming a larger circumference of the arch in that area, the teeth will also separate – so the SPACES will be back again! He will have made room to place composite on the edges of the teeth without disturbing the bite, but her primary cosmetic complaint for her lifetime will resurface.
Turning a $300 case into a $12,000 case ….
IF she allowed him to do as he wants, then she would complain about the spaces, and his solution would probably be to do porcelain veneers over the teeth, allowing the spaces to be filled and the teeth to look as if they are in the usual contact. Cost for this would be $1000 to $2000 per tooth, with six teeth required – total $6000 to $12000, in addition to the earlier procedures. AND, the veneers cover the edges, removing the composite that the dentist had placed there in the first place. Additionally, with porcelain over the edges of her upper teeth now, her grinding habit will be devastating to the lower teeth, cutting them down because of the abrasivity of porcelain!
So, considering that the dentist COULD have simply polished out the rough edges in the first place and the patient would have been happy, and charged her something like $300 – how is she supposed to deal with a plan that ultimately will cost at least $10,000 – even if she can afford it?
Case 5: Fourteen year-old boy that is extremely anxious about going to the dentist.
This teenager was never a patient of mine as a dentist, and not a therapeutic client, but I presented his case to a Somatic Experiencing practitioner as a case consultation – so I could learn more about what might be going on in dental phobia.
Observations in Dental Office:
D. hated going to the dentist, although he had never had any particularly traumatic dental treatments in the past.
He had an extreme fear of needles, but this started even before his first dental visit.
When in the dental office for an appointment he is always resigned and passive, while before arrival he would be quite anxious. Those observing him in the waiting room see a marked change from agitated to lethargic. In the dental chair he would always be extremely passive.
A family member was a Family Therapist and felt D. had Sensory Processing Disorder, an acute sensitivity to sensory stimuli, but after some treatment for this condition, the visits to the dentist were unchanged.
D.’s mother was also highly anxious about many things, and after giving birth fell into a depressive pattern that resulted in a failure-to-thrive situation for D. When D. was fed more regularly he gained weight, but the sadistic father would tease him with the bottle of formula – offering it and then withdrawing it suddenly.
With the Mother in a constant state of overwhelm and not able to connect with D, and the Father not believing in any kind of therapeutic assistance, D. was clearly not developing along desired lines. It is well known that during the first two years a particularly strong connection with the Mother is vital for the healthy development of the nervous system.
As an older child he would spend a lot of time in the bathroom to avoid the Father.
Observations in a Therapeutic Consulting Session:
D. was hypervigilant – eyes darting rapidly around looking for signs of danger.
At times during the session he would dissociate, lie sideways in the chair, close his eyes and let his body go limp.
He was clearly not connecting with the discussion in the room during the session.
Possible Approaches for Helping D.:
What the Dentist might do:
The fact that D. is anxious before arrival, jumpy and agitated when arriving, and lethargic afterward may suggest that he is “shutting down” to protect himself from perceived danger. This is much as an animal would “play o’Possum” when exposed to a severe threat. Part of the nervous system simply stops all function – it is effectively what we would call a “freeze”.
In the dental office it is necessary to attempt to decrease as much as possible all unnecessary stimulation. This stimulation could be from unusual smells, harsh lights, or the sounds associated with the dental office, whining handpieces, the gurgling of suction tubes, etc. It could even be from movements near his head.
I would find the most isolated and quiet dental chair for D. to go to immediately upon arrival – and make sure that he can sit there calmly for a few minutes, with pleasing distractions instead of strong sensations. The staff members need to speak calmly to him. The chair should be positioned comfortably and the lights lowered – and perhaps even some aromatic oil to give a different scent to the area.
D. apparently has a very small window of tolerance, and it would be the goal of the office staff to keep him in the range where he is aware of his environment but feels safe enough to stay connected and not go into a freeze.
If a dental procedure is required that involves injection of anesthetic, the technique must be flawless, as if it were being given to a small child – and the anesthetic must not include adrenaline, as most do – for that could stimulate his fight/flight responses and likely provoke a shutdown.
Also it might be helpful for the dentist and assistants to encourage D. to move his arms and legs around at various times so that he can feel himself moving within the environment of the office – this can prevent collapse.
What a Therapist might do:
One thing a therapist might do with D. is to work with movements around his head and toward his mouth. Slowly moving a dental mirror around his face and toward his mouth could stimulate a shutdown response – so if this is titrated by the therapist, perhaps a desensitization may be accomplished.
Likewise a therapist may use scents, sounds and lights to desensitize D. toward these stimuli. It is possible that this will help if the therapist is skilled enough in tracking D.’s responses and makes sure to teach him how to be aware of his tendencies to react, recognize when it is about to happen, and manage his reactions.
But, recognizing what has caused this reaction on D.’s part is particularly important. One is certainly tempted to hypothesize that, with the Father presenting sustenance – and at that point stimulating the nervous system to a high pitch in expectation of needed nourishment – the sudden withdrawal of this will result in a protective shutdown of the child. If this is the case, this pattern in the nervous system could well persist until the teenage years, or much later.
While this perinatal circumstance MAY be the cause of D.’s reactions, it needs to be discovered by patient and insightful therapeutic sessions. These sessions should be conducted by someone who understands how to work with patterns in the nervous system, particularly those associated with repeated trauma, or what in this case could be, effectively, ritual abuse.
As the therapist guides D. to use images or even smells to stimulate arousal, and then guides him back to the room before shutdown happens, eventually D. may be organically able to pendulate back and forth between arousal and a calm from which he can still be responsive, as opposed to dissociation, collapse or shutdown.
After some time, building self-awareness and finding tools that help D. to navigate the kinds of stress reactions that he finds in the dental office (and undoubtedly elsewhere), his reactions may become far more normalized.
The actual event or events that resulted in this pattern of responses in D.’s nervous system may never be discovered, but the pattern can likely be slowed down, teased apart and stabilized so that D. can function normally in most circumstances.
While my skills as a Somatic Experiencing Practitioner have not advanced to the point where I would be an appropriate therapist for D., over the next few years and with the kind of guidance I have in the field, I hope to be able to help most individuals dealing with this complex situation.
Bottom line for case presentations:
KNOWING something about what is going on is your protection. Being educated in dental procedures and decisions independently, not just relying on what your dentist tells you, is the KEY.
It may be challenging for your dentist to perform services that are rather creative, to work within your budget – but it is often a possibility. And, if your finances are sufficient to support the most expensive treatment, is that the BEST treatment?