Solving Dilemmas in Clinical Practice

[drmithila]

 Examination and Analysis 

A problem-focused examination of the anterior teeth with the aforementioned veneers that were placed just a few short hours ago was completed. No x-rays were taken on this day, and a comprehensive examination was not appropriate at this time. The questions to be answered were simple but the answers were not. What was wrong? What could be done? If something was wrong, how would I convey that to the doctor who treated Gina that morning? Should I consider doing something and assume the responsibility/liability that would occur immediately after touching the veneers? Do I send Gina back to the practitioner who placed the veneers? This was a medicolegal and ethical dilemma.

     Examination revealed improper axial inclinations, open margins, poorly shaped veneers, and gross cement excess (Figure 1). I went into my private office, called the treating dentist, and discussed the situation. I described what I saw and he said I should send her back to see what he could do. I told him I would suggest that and the decision would be hers to make. I felt I had fulfilled my obligation to a colleague; however, I had mixed feelings about it. I was troubled because I had already seen what he had done. When I spoke with Gina, she refused to go back. Now what? As you see, this is a true dilemma; you observe technically substandard care and yet do not want to be held liable if you touch the previous dentist’s completed case. 

     I empathized with this young woman and wanted to help her but at the same time protect myself from liability for what another practitioner had done. I wrote a simple statement describing the situation, what I would do on an emergency basis, and that this care was not a substitute for a comprehensive examination and future treatment to correct the problems. I concluded this statement with Gina, agreeing I would not be responsible if the laminates were to chip or break when I adjusted them. She signed the statement in the presence of my clinical assistant, who witnessed it. The "release of liability" statement I created is in Figure 2. 

     Without belaboring the point, the deficient margins and residual cement are some examples of what I saw (Figure 3). With some recontouring and repolishing, I was able to improve the existing veneers somewhat by correcting the shapes and axial inclinations, allowing Gina to go out without feeling embarrassed. The poor margins were not addressed at this time. A few days later, we took a complete history and performed a complete evaluation. This included a visual oral cancer screening and examination of all soft and hard tissues. A subsurface examination for abnormal tissues was performed with the VELscope (LED Dental). Periodontal evaluation was done with a 3-6-9-12-mm probe (Premier PerioWise [Premier Dental]), a full-mouth series of x-rays was taken, and diagnostic model impressions were made using an alginate substitute (Position Penta Quick VPS Alginate Replacement [3M ESPE]) in a stock tray (Originate Disposable Impression Tray [AXIS Dental]).

     It was apparent that this lovely young woman had many problems that needed care, in addition to her smile. However, she opted to deal with her veneers before taking care of the other necessary restorations. In order to determine what Gina wanted her smile to look like, we spent time reviewing photos of various smile designs, tooth shapes, and discussed shades and incisal translucencies. Dental terminology was avoided and a simple "I like it" or "I don’t like it" from Gina helped me to understand what her preferences were. A diagnostic aesthetic wax-up for 8 new veneers was created based on the information gathered during our conversation. She reviewed the wax-up and said she liked it.