Crappy Dentistry Today
Started by JavadiCavity
Is the Javadi man back? Sorry about the bad day...
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Two words: it happens. 🙂
Endo cases , even "simple" ones, can have a lot of hidden obstacles. As for #31, everyone knows second molars can be a bear to get decently prepped. Just make sure to learn what you can from whatever went wrong, and next time I'll bet you recognize those potential problems early enough prevent them ahead of time.
Just one of those days. Seems like I couldn't wrap my head around the endo. Apex locator told me the apex was at 20 mm, but the x-ray said I was 2 to 3 mm short. To make matters worse, I blocked myself out of the mesial canal and had to reestablish patency. But, even then, after having two endodontists take a gander, I made no progress. I was still 2 to 3 mm short. Finally, the doctor said to obturate, and so I did. But, it's just not the kind of dentistry I'm happy with. I like to see things turn out the way they are supposed to turn out.
As for the crown prep, I've done better. I placed the build-up, and then I had to go way sub-g on the mesial to get a finish line on tooth and not on paracore. In the process, I made a wider chamfer then I like. On the lingual, I made a deeper chamber than normal because yesterday I had trouble getting a good impression on a different molar due to a chamfer margin that was too shallow. I mean, in both cases (the mesial and lingual, we are talking between .5 to 1mm deeper than ideal. Just wasn't pretty. The distal and the buccal were great, but the rest was crap. I just sat there looking at the prep. I kept telling myself I do better work than that. But, it was done.
And, on top of that my patient acted like a little girl. I administered 2 carps of lido for an IAN block, and I gave him a mesial and distal PDL injection. Two hours later, he's crying for more. So, I pump some 4% articaine into IAN area (a mild contraindication for parathesia, but the doctor said to try it), and he's crying during the injection. Are you kidding me? Patients never complain about my injections. I was ready to tell the guy to stop acting like baby.
Anyway, I rant. Tomorrow will be better. I just need some sleep.
As for the crown prep, I've done better. I placed the build-up, and then I had to go way sub-g on the mesial to get a finish line on tooth and not on paracore. In the process, I made a wider chamfer then I like. On the lingual, I made a deeper chamber than normal because yesterday I had trouble getting a good impression on a different molar due to a chamfer margin that was too shallow. I mean, in both cases (the mesial and lingual, we are talking between .5 to 1mm deeper than ideal. Just wasn't pretty. The distal and the buccal were great, but the rest was crap. I just sat there looking at the prep. I kept telling myself I do better work than that. But, it was done.
And, on top of that my patient acted like a little girl. I administered 2 carps of lido for an IAN block, and I gave him a mesial and distal PDL injection. Two hours later, he's crying for more. So, I pump some 4% articaine into IAN area (a mild contraindication for parathesia, but the doctor said to try it), and he's crying during the injection. Are you kidding me? Patients never complain about my injections. I was ready to tell the guy to stop acting like baby.
Anyway, I rant. Tomorrow will be better. I just need some sleep.
We all have bad days. If I were you, I would have delayed the crown prep for another appointment. First, you had been frustrated with the endo, I would rather stop at the buildup and do the rest when I'm fresh again. Second, if the patient complained about your injection, you should listen to the patient even if you had been told that your injections were painless. You know that anatomy varies significantly from person to person. So does pain threshold. Changing this type of patients is nearly impossible. Thus, it's best to change our ways of doing the procedure. Also, if you can't get a patient numbed with 2-3 carpules, I don't think you should push more. Maybe that's just me. Trying too hard to get the IA block can lead to some serious disasters. I'm sure tomorrow will be better for you. Good luck!
Dentistry is pretty funny in that when things go wrong, they really go wrong. Been there. Done that. Just remember that you learn way more from days like that than you do from days that go right.
Don't sweat it, we all have those days. Personally I find that a few days later when your mentally back in the game, if you look back at what happened, you'll end up learning more from those types of days than from the days where everything goes perfect
As for your beating yourself up about being a bit more agressive with the crown prep and the width of the margins, while it migth drive you crazy, believe me the lab will LOVE having that extra space! One of the most common requests you'll find a lab tech making to a doc and/or wishing the doc would do is give them MORE space to use for crown + bridge fabrication.
Endo wise, hey, there are literally millions of perfectly functioning canals out there where the gutta percha stops a few mm short of the radiographic apex.
Remember we PRACTICE dentistry, maybe someday we'll all get it right😀
As for your beating yourself up about being a bit more agressive with the crown prep and the width of the margins, while it migth drive you crazy, believe me the lab will LOVE having that extra space! One of the most common requests you'll find a lab tech making to a doc and/or wishing the doc would do is give them MORE space to use for crown + bridge fabrication.
Endo wise, hey, there are literally millions of perfectly functioning canals out there where the gutta percha stops a few mm short of the radiographic apex.
Remember we PRACTICE dentistry, maybe someday we'll all get it right😀
Better short than long I always say
Every Dentist has days when it feels like they have 10 thumbs. Relax, tommorrow will be better. You will have days like that periodically throughout your career. The good thing is that you noticed the problems and want to do better work. As for the endo, there are some times when the canal ends 2-3mm short of the radiographic apex.
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Naw...this guy is a baby. It wasn't our first appointment, and no matter what injection I give, he cries. And, rescheduling, although it makes sense when you aren't involved, wasn't an option the patient was interested in. Plus, who is going to say to their patient who drove a long distance to get to the dentist and took the day off work that you need to stop the appointment because you don't feel on the top of your game--patient's don't want to hear that and they don't understand how that's possible. The reality is that my work wasn't up to the standards I like, and I'll do better next time.
Don't sweat it, we all have those days. Personally I find that a few days later when your mentally back in the game, if you look back at what happened, you'll end up learning more from those types of days than from the days where everything goes perfect
As for your beating yourself up about being a bit more agressive with the crown prep and the width of the margins, while it migth drive you crazy, believe me the lab will LOVE having that extra space! One of the most common requests you'll find a lab tech making to a doc and/or wishing the doc would do is give them MORE space to use for crown + bridge fabrication.
Endo wise, hey, there are literally millions of perfectly functioning canals out there where the gutta percha stops a few mm short of the radiographic apex.
Remember we PRACTICE dentistry, maybe someday we'll all get it right😀
Which was exactly the reason I prepped the lingual so deep, but the mesial was only deep because I couldn't obtain good visibility of the area. Trying to find good tooth structure sub-g on the mesial of #31 isn't something I'm proficient at yet. I was disappointed at the over-reduction, but happy I found a place to put to my finish line.
The root canal...well, the endodontist said the same thing you said. I think the frustration comes from wondering what else I could have done; or, not knowing exactly what I wasn't doing that prevented me from getting to length.
With respect to the endo, I hope so doc. It's the first endo I've ever been that short on. I know the patient would hate to hear we have to retreat that tooth, and I don't want it to become symptomatic either.
Well, the apex is different from the apical foramen (hence, the misnomer "apex locator"). What I am trying to say, is I would take the apex locators word for it. The apical foramen could well be to one side of the root or the other, and not necessarily centered where you see that root/radiographic apex.
I'd say you're fine up to a couple of mm's.
Which is fine. Non-vital. The whole issue sounds like you put a deep shamfer/shoulder, where you only needed a shamfer (I'm guessing FVC). Not the end of the world.
The main issue I find with those kind of apical margins on multi-rooted teeth, is including that root "fluting" into my prep, while maintaining consistent margin integrity.
I hope you're feeling better today. We all have these kind of days ...
I tend to agree with nhasigioi on this one.
But then again, much easier said (for all of us) ...
After reading the original comment again, let me be clearer. It wasn't that I didnt' get the patient numb. It was that he was regaining feeling again much faster than I expected. And, he couldn't tolerate the prick on the needle crossing the mucosa. He'll live.
Tough day. As weird as this sounds, I can't wait to have my first bad day (but remind me of this when I have it and I'll probably think I am crazy 🙂). You'll knock em dead tomorrow.
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I finally just picked up a high speed for the first time on a patient to cut off a crown due to recurrent carries. I cut a little too deep and left a nice notch (maybe 1/2 mm) in the amalgam build up underneith. I wasn't happy with it at all then the instructor comes over and says "I like your retentive features" and gives me a little smile. He said it happens and to not let it get you down. That is why we are all still in school. I can tell you though, next crown I cut off I am going to be a lot more anal and hopefully the notch I leave will only be 1/4mm😳
Cutting off crowns is tricky the first couple times you do it. The trick is to recognize the cement line when you've cut through the metal, and to stop before continuing into tooth structure. Once you're there, it's usually pretty easy to break the cement seal and remove the crown with a separator (or just an ordinary #301 straight elevator). The good news is that, just like everything else in dentistry, it gets steadily easier as you do more of them. 🙂
Come on, do you think that the pats are/were the only team doing this. No way. It's just Mangini and the Jets trying to get a psychological edge on the Pats since a huge chunk of the jets is made of players that wren't good enough to make the patriots squad.
The commish was trying to send a BIG message and he did. Do you think that if the allegations had been made against the Raiders or Detriot or some other non contender that the fines/punishment would have been the same????
Bottomline, I'll be wearing my Brady Jersey, sitting in my seat in section 202 row 1 of Gilllette Stadium this Sunday night, proudly cheering my beloved Patriots against the Chargers Sunday night😀
I'll be there. Hopefully we'll have a nice early December snowstorm on the 9th to give some real football weather to play in!😀
Is it true that the Patriots have to forfeit the three SB rings and give them to the runner up? I also heard that every Patriot personel (from headcoach to water boys) has to go through the security gate and complete pat down (for hidden cameras) before they can be at the sideline. And all of this will be done infront of the spectators stands. DP
I can sympathize with you when you're frustrated over the patient that you saw. But the truth is that different people have had different experiences that make them more or less tolerant of these procedures. In your mind it is just a little prick. In his mind it's one of the worst tortures he could endure. Just think about what he's feeling before passing judgement.
As for the anesthetic, you're waaaaay off base here. The thing dental students forget is that anesthesia for hard tissue doesn't last 3 hours, like your appointment times. For mandibular blocks, lidocaine lasts about 1.5 hours. So by the time he "couldn't take it" anymore, he was NOT NUMB. Also, some people clear anesthetic much faster, such that they're not even numb for 1.5 hours. Finally, the average number of carpules needed to fully anesthetize the IA has been estimated to be 2.5 carpules. Maxillary infiltrations require 1.5 carpules.
Concerning the margins, it takes practice. Steady handskills are important. Have you tried magnification? It's hard to see a smooth, even chamfer by naked eye, but it's pretty easy with 5x+.
For the endo, it is better to be short on vital teeth, better long on non-vital teeth. The best, of course, is to be spot on.
any chance the patient was diabetic?
we've learned diabetic patients have a tendency to cry under pressure...wanna know if it's actually true
we've learned diabetic patients have a tendency to cry under pressure...wanna know if it's actually true
Of course I wouldn't tell my patient to reschedule because I'm not on the top of my game. I'm sure a person with the background like yours will have no problem talking the patient into rescheduling. It is your choice to push it through and get done with it. One thing to remember though, when you do great jobs, your patients will most likely not talk about it outside your office unless someone asks. On the other hand, if you hurt your patient (no matter how little you think it may be), most likely the patient will tell others about their unpleasant experience. For now, it is not that critical for you since most likely you'll settle somewhere else after graduation. But that is something you should definitely keep in mind when you open your own office. Good luck!
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nhasigioi or anyone else here,
What do dentists in Vietnam fill the inside of the root canals with after they clean it out? I've seen many endos from there and they're not gutta percha but I don't know what it is. Half the time the obturation material is 1cm (not 1mm) short of the apex but the patient rarely has pain.
What do dentists in Vietnam fill the inside of the root canals with after they clean it out? I've seen many endos from there and they're not gutta percha but I don't know what it is. Half the time the obturation material is 1cm (not 1mm) short of the apex but the patient rarely has pain.
1.5 hours? Wow. Based on my experience, 1 carp of lidocaine does the trick for a 3 hour appointment. For endos, I generally give two. But, you're right. And, I don't get frustrated with patients for wanting to be numb or for being afraid of the needle. I've been there, and I remember how stressful "the shot" can be.
Honestly, I wasn't really irritated with him. He just made such a big deal out of the whole deal. If he could, he'd tell you I go to great lengths to make sure he's comfortable--same with the rest of my patients. But he's a baby. No matter who gives him the injection (me or the doctors), he hates it. I can't make everyone happy, but I get at least 9.5/10.
And, while we are on the point, I'm happy if he wants to go somewhere else for his dentistry. I certainly wouldn't go back to a dentist who hurt me. True, he'll tell his friends, but what can I do about it. Some people aren't going to like their dentist for whatever reason--over diagnosing, painful injections, high fees, snooty staff, poor chairside manner, etc. I'd rather not see these patients on my schedule, so the feelings between me and these patients are mutual.
I'm sure you're a very conscientious person. The fact that you're thinking about such minute details as margin thickness is a credit to your maturity and caring for others. You definitely want to continue the attitude of striving for perfection while understanding that your skillset will always be limited --- we're human. Do the best you can, be proud of your work, and at the end of the day, go home and leave it behind. It's easier said than done. But for your own sanity, and those who have to listen to you rant (usually the wife), keep your professional and personal lives separate. After you graduate I'm sure you'll be an excellent clinician. At that point, you can decide what type of practice you'll run. And that can mean that you'll dismiss patients that do not fit your mold. As you said, it really is in the best interest of the patient to see a dentist he/she feels comfortable with. And the same goes for you... you have to feel comfortable treating the patient that you see so that you can put your best efforts forward.
I'd never thought about this, but it makes a lot of sense. Thanks for the tip. 👍
The coolest two things at the game last night, was 1) in the pre game introductions, they actually introduced Coach Belicheck and the ovation he received was as load as any I've ever heard in Gillette Stadium(and I've only missed 4 games there since it opened 5 years ago) and 2) A fan sitting in the next section over from me had taped a videocamera to the top of the hat he was wearing
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