This question would be suitable for any dental classroom. This is a true situation. What is a possible diagnosis and where did the dentists below fail in treating this patient.
A 38 year old male is recommended by his general dentist to seek orthodontic treatment due to a 12mm bilateral crossbite. The patients dental history is ideal having only amalgam filling in the first and second molars as a teen and has a 20 year history of no caries. Patients occlusion is stable, but reversed due to crossbite.
Patient receives periodontal and dental clearance.
Patient visits orthodontist. Orthodontist chooses to treat non-surgically with a palate expander for 7 months and fixed braces for the remainder for 1.5 year to two year treatment. Patient requests clear bracket's for aesthetic reasons. Patient is not given informed consent. No treatment plan, other than length of time and cost is provided to patient (no ceph drawing, no diagnosis communicated, risks versus benefit of treatment, ceramic braces, root resorption, etc
.
Patient makes every appointment. Patient is in removable expander for first 14 months. Fixed braces applied after for a period of 28 months (42 months total). At month 30, the orthodontist puts in a thick rectangular wire and begins extruding the teeth on the right side with labial movement of the lower anteriors. Patient complains of gum and interdental papilla loss as the teeth on the right side extrude. Patient is told it is not gum or bone loss and not to look in their mouth as treatment tends to look worse before better. The arch wires are round versus a "V" shape which is the shape of the patient's jaws. Patient does not look in mouth until month 38. The results are flattening of the interdental papilla, long teeth due to extrusion, gum recession in the anteriors, a cant due to extrusion of right side and edge to edge occlusion in the posteriors. Patient visits two universities who recommend removal of braces due to iatrogenic response. Month 38, orthodontist has assistant remove brackets unsupervised. Assistant does not use the recommend tool for debonding patient's particular bracket. All the teeth crack to some degree as well as chunks and pieces of enamel are removed with the bracket. Final bracket would not remove. The orthodontist comes over to the patient, clasps on the bracket twists and yanks the bracket off causing cracking and removal of enamel.
Patient leaves to get teeth cleaned at general dentist. Patient returns for Essix Retainer C+. The retainer does not fit the patient. Patient requires significant force to put it. Retainer does not fit the duplicate cast without significant force. The retainer is cut to the interdental papilla points leaving the upper 1/4th of the tooth exposed. Retainer is forced in and binding and significant force is required to remove. Patient is advised to take Tylenol and the fit is appropriate. No occlusion is checked.
Patient goes to university that advised removal. CT Scan shows root resorption. Told most likely cause is orthodontist not taking xrays during treatment as well as non-surgical attempts and length of time in braces. Periodontist informs that he has bone loss which accounts for loss of interdental papilla and informed no predictable procedure exist to repair. CT scan also shows all of the patients teeth outside of the bone. Patient experiences food entrapment and inability for teeth to close due to edge to edge occlussion. Cant prevents teeth on left side from closing.
Patient returns to office claiming the retainer's compressive forces cracked his teeth (craze lines and cracks in molars with large fillings). Patient is advised that this is not possible and dismissed from practice.
Patient goes to restorative dentist for repair of all the cracked molar teeth in traumatic occlusion. Pays $11K plus $4K in travel costs as DDS was located out of state. All fillings are large. Tooth is layered with Gluma Bond and a flowable composite and polished. Patient has post operative sensitivity. Patient is told this is normal. Patient is told to continue wearing Essix Retainer. Patient complains that his teeth feels like they are in a vice - significant pressure and pain. Patient is advised it's tooth movement and to take an anti-anxiety pill. Pain does not decrease. Patient is reviewed for pain. No xray is taken and a visual occlusal exam is performed. Patient advised teeth are fine. Patient continues to communicate increase symptoms. Patient is advised pain is due to anxiety. Patient communicates continued symptoms. Patient is dismissed from practice. Patient is advised not to see any other dentist because pain is systemic and practitioner may do needless dental procedures. Patient communicates that he feels something went wrong procedurely as all the teeth restored are in pain. Offers laymen opinion that it could be contaminated filling, pressure and destruction from wearing previous retainer post restorative.
Patient does not see another DDS in fear that he'll be subject to unneeded procedures as warned by operating DDS.
Patient takes percocet and aleve to reduce pain. Pain is unresponsive to percocet after several months. Patient visits several DDS. DDS explain to the patient that due to the large amount of work, he should report back to original dentist who performed the work. Patient's original dentist refuses to see the patient. Patient attempts to see several dentists who have heard through the grapevine that patient is "dentist shopping" in order to receive care. Dentists refuse to see patient. Patients symptoms include pain upon drinking water of any temperature, form fitting food, pain when teeth touch.
Several months later, patient reports evidence of irreversible pulpitis. Patient is unable to breath air, pain is consistent low intensity throb. The slightest touch illicits extreme sensitivity. Patient is convinced the compressive forces of the retainer are the cause. Evaluation of insical edges show cracking at all 3 edges of the teeth with numerous craze lines labial and lingual. Patient had sleep study performed showing no bruxism. Patient has worn as directed the original bonding retainer and fabricated himself a soft retainer to be placed over the front teeth (with retainer in) to keep the teeth seperate in the posterior during sleeping (a somewhat homemade version of an NTI device).
Has this patient been treated appropriately? Is the patient receiving "standard of care" treatment? What is causing the patient's symptoms? Who is responsible for what the patient is experiencing? What would you advise this patient? Would you treat this patient? Why and/or why not?
A 38 year old male is recommended by his general dentist to seek orthodontic treatment due to a 12mm bilateral crossbite. The patients dental history is ideal having only amalgam filling in the first and second molars as a teen and has a 20 year history of no caries. Patients occlusion is stable, but reversed due to crossbite.
Patient receives periodontal and dental clearance.
Patient visits orthodontist. Orthodontist chooses to treat non-surgically with a palate expander for 7 months and fixed braces for the remainder for 1.5 year to two year treatment. Patient requests clear bracket's for aesthetic reasons. Patient is not given informed consent. No treatment plan, other than length of time and cost is provided to patient (no ceph drawing, no diagnosis communicated, risks versus benefit of treatment, ceramic braces, root resorption, etc
.Patient makes every appointment. Patient is in removable expander for first 14 months. Fixed braces applied after for a period of 28 months (42 months total). At month 30, the orthodontist puts in a thick rectangular wire and begins extruding the teeth on the right side with labial movement of the lower anteriors. Patient complains of gum and interdental papilla loss as the teeth on the right side extrude. Patient is told it is not gum or bone loss and not to look in their mouth as treatment tends to look worse before better. The arch wires are round versus a "V" shape which is the shape of the patient's jaws. Patient does not look in mouth until month 38. The results are flattening of the interdental papilla, long teeth due to extrusion, gum recession in the anteriors, a cant due to extrusion of right side and edge to edge occlusion in the posteriors. Patient visits two universities who recommend removal of braces due to iatrogenic response. Month 38, orthodontist has assistant remove brackets unsupervised. Assistant does not use the recommend tool for debonding patient's particular bracket. All the teeth crack to some degree as well as chunks and pieces of enamel are removed with the bracket. Final bracket would not remove. The orthodontist comes over to the patient, clasps on the bracket twists and yanks the bracket off causing cracking and removal of enamel.
Patient leaves to get teeth cleaned at general dentist. Patient returns for Essix Retainer C+. The retainer does not fit the patient. Patient requires significant force to put it. Retainer does not fit the duplicate cast without significant force. The retainer is cut to the interdental papilla points leaving the upper 1/4th of the tooth exposed. Retainer is forced in and binding and significant force is required to remove. Patient is advised to take Tylenol and the fit is appropriate. No occlusion is checked.
Patient goes to university that advised removal. CT Scan shows root resorption. Told most likely cause is orthodontist not taking xrays during treatment as well as non-surgical attempts and length of time in braces. Periodontist informs that he has bone loss which accounts for loss of interdental papilla and informed no predictable procedure exist to repair. CT scan also shows all of the patients teeth outside of the bone. Patient experiences food entrapment and inability for teeth to close due to edge to edge occlussion. Cant prevents teeth on left side from closing.
Patient returns to office claiming the retainer's compressive forces cracked his teeth (craze lines and cracks in molars with large fillings). Patient is advised that this is not possible and dismissed from practice.
Patient goes to restorative dentist for repair of all the cracked molar teeth in traumatic occlusion. Pays $11K plus $4K in travel costs as DDS was located out of state. All fillings are large. Tooth is layered with Gluma Bond and a flowable composite and polished. Patient has post operative sensitivity. Patient is told this is normal. Patient is told to continue wearing Essix Retainer. Patient complains that his teeth feels like they are in a vice - significant pressure and pain. Patient is advised it's tooth movement and to take an anti-anxiety pill. Pain does not decrease. Patient is reviewed for pain. No xray is taken and a visual occlusal exam is performed. Patient advised teeth are fine. Patient continues to communicate increase symptoms. Patient is advised pain is due to anxiety. Patient communicates continued symptoms. Patient is dismissed from practice. Patient is advised not to see any other dentist because pain is systemic and practitioner may do needless dental procedures. Patient communicates that he feels something went wrong procedurely as all the teeth restored are in pain. Offers laymen opinion that it could be contaminated filling, pressure and destruction from wearing previous retainer post restorative.
Patient does not see another DDS in fear that he'll be subject to unneeded procedures as warned by operating DDS.
Patient takes percocet and aleve to reduce pain. Pain is unresponsive to percocet after several months. Patient visits several DDS. DDS explain to the patient that due to the large amount of work, he should report back to original dentist who performed the work. Patient's original dentist refuses to see the patient. Patient attempts to see several dentists who have heard through the grapevine that patient is "dentist shopping" in order to receive care. Dentists refuse to see patient. Patients symptoms include pain upon drinking water of any temperature, form fitting food, pain when teeth touch.
Several months later, patient reports evidence of irreversible pulpitis. Patient is unable to breath air, pain is consistent low intensity throb. The slightest touch illicits extreme sensitivity. Patient is convinced the compressive forces of the retainer are the cause. Evaluation of insical edges show cracking at all 3 edges of the teeth with numerous craze lines labial and lingual. Patient had sleep study performed showing no bruxism. Patient has worn as directed the original bonding retainer and fabricated himself a soft retainer to be placed over the front teeth (with retainer in) to keep the teeth seperate in the posterior during sleeping (a somewhat homemade version of an NTI device).
Has this patient been treated appropriately? Is the patient receiving "standard of care" treatment? What is causing the patient's symptoms? Who is responsible for what the patient is experiencing? What would you advise this patient? Would you treat this patient? Why and/or why not?
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