Advice on preventing clinical dentistry failures

July 20, 2012

There can be no argument that dentistry is a challenging profession. Not only must we manage a business and employees, we also must  manage clinical care and patient expectations. When a doctor is pulled in various directions it’s easy to let some details start to fall through the cracks-that’s when we experience failures.  

There can be no argument that dentistry is a challenging profession. Not only must we manage a business and employees, we also must  manage clinical care and patient expectations. When a doctor is pulled in various directions it’s easy to let some details start to fall through the cracks-that’s when we experience failures.

 

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When you sit down and think about it, there are so many ways to fail when performing clinical dentistry; the list of ways could fill up this entire journal. Much of what we do is highly technique sensitive, which invites failure. In addition, mistakes made early in a procedure or case, and not realized, often get magnified at the outcome. This can make a small mistake result in a tremendous failure! Take resin bonding for instance. It’s either a 100% success or a 100% failure! There is no in between.

Three major forms of clinical failure
In the oral cavity there are two factors that affect the health of the mouth and lead to failure: bacteria and force management. If these two factors are managed, the patient can be expected to have success. Patients must be educated on proper hygiene and present for their routine exams to monitor restoration integrity. This is usually enough to manage bacteria related issues with regard to decay and periodontal health (Fig. 1).

Failures due to force management are much too common in restorative dentistry. Broken or chipped teeth (Fig. 2) and restorations are often part of a larger problem (Fig. 3). Yet, we like to blame a faulty lab or patient neglect for the problem. Force management is a much more complicated issue to control, yet simple if approached in a systematic manner.

Occlusal health and management are the responsibility of the practitioner. Many times patients will have severe functional issues and not realize they have a problem. Just as heart disease can be a silent killer due to lack of patient perceived symptoms, the doctor must recognize the signs and symptoms and properly diagnose the issue.

A restorative dentist must learn to recognize the signs of instability in the stomatognathic system. In the dentition one must look for wear beyond normal, migration of teeth into unwanted positions, and the abnormal mobility of teeth2 (Figs. 4-5). The muscles of mastication should be free of inflammation and soreness. The temporomandibular joints must be in their proper disc and condylar position in centric relation. If the joints are not healthy and functioning from a stable position, then any changes to the dentition cannot be expected to be stable. Occlusally, there should be equal intensity stops on all teeth or an acceptable substitute3. There should be no posterior tooth contact in an excursive movement, and the anterior guidance should be in harmony with the envelope of function. Neglecting any of these four requirements will often have negative consequences for a patient’s occlusion (Figs. 6-7).

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Esthetic and/or patient comfort failures would be the third consideration for purposes of this article. There are numerous factors involved in deciding where restorations should be placed, not only for function but also esthetics (Fig. 8). If a case comes out functionally correct, but the patient is unhappy with the esthetics, then the case is a failure. Conversely, if a case is beautiful to the patient but functionally deficient, the case will again fail even though the patient started out pleased. In addition, a case may look good but remain uncomfortable to the patient’s soft tissues or lip closure paths. Or the patient may have speech difficulties due to a horizontal incisal edge position error5 (Fig. 9).

Dr. Peter Dawson has always said, “Failing to properly plan is planning for failure!” At The Dawson Academy, treatment planning is taught as to simplify the process through a 16-step 2D checklist. By planning every case the same way with the checklist, the doctor will be sure to meet functional and esthetic requirements for restorative success.

The information gathered in the 2D checklist is then applied to a 10-step 3D checklist used during the diagnostic phase. Many functional and esthetic failures occur because of lack of diagnostic planning and failure to communicate properly with the ceramic laboratory. The decision as to where to place incisal edges and tooth contours should be decided by the dentist and refined in the mouth with provisional restorations. Successful provisionals provide the blueprint used to create the final ceramic restorations (Figs. 10-12).

 

At what cost?
What is the true cost of a clinical failure? There are different ways to look at failures. Monetarily is the most common way to look at a failure because it is the easiest way to “feel” a failure. A failed crown requires additional chair time, lab fees and material costs. When you sit down and really add it all up, a failure means you lost money on that unit of C&B.

There also may be a loss to your professional reputation when a failure occurs. There is the old saying, “When a customer is happy they will tell 1 or 2 other people, when they are upset they will tell 10 people.” How we handle a failure with a patient from a public relations standpoint then becomes critical. We really must manage the failure and the response with deft care and compassion. Honesty is always the best policy.

A third way failures can affect our practices is the impact on our staff. And I think this impact may often be over looked. Having your staff believe in your practice and what procedures you perform is critical. Patients often will ask your staff questions they feel embarrassed to ask the doctor. They may also bluntly ask staff members if this is what they would do for themselves. If your staff doesn’t feel confident in the work being performed at the office, a patient may sense this and be reluctant to move ahead with treatment.

Conclusion
Failure is a part of life and will always be a part of clinical practice. A failure can become a negative or a positive force in our careers, but that will be an individual choice. I use failures as a sign of what needs attention and work. I can remember years ago having problems with lateral incisor restorations developing incisal chips in the mouth. The problem was lack of attention to the patient’s occlusion and anterior guidance. Through education and practice, this is hardly ever a problem in my practice today. Those failures ignited the desire to learn more and succeed.

Making a complete diagnosis, and then properly treatment planning for  function and esthetics, will decrease failure. Proper planning leads to less remakes, fewer unhappy patients, and a more fulfilling and profitable practice.