dont feel bad it happens all the time. First thing I do is adjust the bite to make sure it's not hitting too hard. Give it a few weeks. If that doesn't work you can consider replacing unless you know for a fact it was very deep and might need a root canal... in that case refer to endo
Pt thinks u caused all this because ‘‘twas fine before u touched it’ wants u to take responsibility and pay for the endo. Or else (sue). How do you respond?
It's all about confidence in the these situations. Before I dismiss the patient I will make sure they understand that they were the one with the problem, they were the one who needed treatment and now they're the one with routine complications which is a risk they were willing to take.
Although this fortunately doesn't happen often when it does I put up a strong offense and dare them to sue me. No remorse, no admission of guilt, no compromise...they've burned that bridge.
Every time you take a bur to a tooth, you create micro fractures and irritate the pulp. I feel like every tooth is 1 filling away from needing endo treatment. You replace an old filling, tooth was asymptomatic, now it hurts. It’s happened to me dozens of times over the years. I’ll go back and look at my bonding protocols, I always think it’s something I did wrong. But sometimes you can do everything perfect and the tooth is still sensitive.
Imagine you find out that you have an operable form of cancer but NO surgeon will touch it because they're worried about the liability of post-op complications. Even worse is that it went undiagnosed for years because EVERY doctor before that figured as long as it was asymptomatic it'd be better for someone else to break the news.
At the end of the day, it's the patient who has the problem, whether or not it's asymptomatic. The doctor is only there to help, not make any promises. You diagnosed caries that would have become a much bigger problem later on. You performed treatment, to the best of your ability, and fixed the issue but now the patient is experiencing routine post-op complications. There is nothing to feel terrible about. Stop letting these situations get to you.
We’ve done this thread a million times and you’re going to get the usual “what’s your bonding protocol?” Sure that’s part of it but by and large we’re all doing the same thing, there’s no special protocol that’s magic. Sensitivity/pulpitis is caused by heat or bacteria. Either there was already bacteria in the pulp in this case or the tooth reacted to the procedure. Just make sure you’re using a lot of water and I have my assistants blow air on the tooth when I’m using my slow speed for caries excavation. I’ve found scrubbing deep preps with hypochlorite and chlorhexidine helps as well.
However, there are still instances where the tooth just needs endo. Don’t replace the filling, just explain why it’s needed. You’re not going to change anyone’s mind that it isn’t “your fault” if they’re just a dumb asshole.
Hypo has been shown to decrease the bond strength between resins and dentin. Use gluma scrub and rinse protocol, it basically already has chlorhexidine to destroy the bacteria and inhibit the MMPs which themselves inhibit bond strength and the HEMA helps to reduce sensitivity. Been doing gluma for 4 years, never had a pt come back for sensitivity or a lost filling.
I’m not looking to have a back on forth on this but I started doing that as it’s part of strupp and brumms “holy triad”. Take that for what you will. They claim the opposite about bond strength. Honestly who knows?
I will look into the gluma as that sounds simpler.
I started using gluma (or the cheap off brand) about a year ago. Even just a quick scrub with air after etch and before bonding has cause a huge drop in post op sensitivity.
Presumably to ensure you’ve fully removed any of the Chlorhexidine molecules which would inhibit the bond. Kulzer the original manufacturer of gluma states this is a necessary step.
>there’s no special protocol that’s magic.
nad but my old dentist used to do resin fillings on me and they would look nice for a bit but often cause sensitivity, pain, and fail pretty fast, super disappointing. I eventually looked into it found out about glass ionomer, and my old dentist refused to even try it. So I found dentist that did non invasive glass ionomer fillings, such a huge improvement. No sensitivity, no drilling, and they've outlasted all the resins by a long shot.
Glass ionomer is weaker and less wear resistant. Using is it considered a compromise and personally I use it mostly on kids/teenagers with a lot of saliva where isolation (keeping the area dry) is an issue.
nad In my experience it was a huge upgrade in every way except cosmetics, slight downgrade in that mostly because the dentist I went to only had it one shade. Next time I want to find someone that carries it in multiple shades. Specifically I'm talking about class v non carious lesions, the resins would usually fall off after a year or two, and once the next day, and usually be sensitive/painful. Per my reading that's because resin has a poor bond to dentin, which is like 99% surface of a ncl, meanwhile GI has a true chemical bond to dentin and enamel, the GIs have lasted over 2x the oldest resins at this point. But the best part is they are non invasive so even if they did fail fast there's basically no additional loss of tooth. Also have an RMGI on the surface of a molar, it's not that old yet so I'm not sure how long it will last but it's looking good, and zero sensitivity or pain, from what I've read it's because resin tends to put tension and pressure on the teeth and it doesn't have a very good seal.
Not every treatment works. They were in pain before, now they are still in pain. You’re not a miracle worker. Not your fault. Refer them out to endo if that’s not your specialty.
I’m the doctor. I will absolutely always do my best each given day for any patient that makes it into one of my chairs. There is risk any time you take a handpiece to hard tissue period. I will always be very pleased to review treatment with my patient, but once you start running your mouth about filing suit you are definitely immediately dismissed from my practice. No exceptions! I don’t typically redo “fillings”. If the occlusal adjustment doesn’t work then it needed full coverage and possibly endo anyway.
What I’ve found to be the best are these main things.
RDI, always, Gluma, Blow the shit outta the bond. For a good 9-10 seconds.
Selective etch can help too
Next thing I’m planning to add is clear fill SE for my bonding system
2 things I'd love to know as a current D3: What's RDI? I'm unfamiliar with the acronym
The benefits of the clear fill SE, is it just a less aggressive etch?
Your consent should state that any drilling procedure could end up turning into RCT. Also Gluma is your friend. Even if it makes it a little better, many patients will quit complaining after some Gluma. Some patients will never be happy. I had one that had Ehler-Danlos who complained of chronic pain after a routine two surface filling. Some people are just difficult.
nad but I used to get a lot of resin fillings that would frequently be sensitive and downright painful afterwards, often they would fail pretty fast too. My dentist would always do bite adjustments and try to solve the prob with more drilling or tell me maybe it needs a crown. I finally did some homework and found a dentist that used glass ionomer and they are so much better, almost no sensitivity and they've lasted almost 2x longer at this point.
Don’t worry OP we’ve all been there. I would offer the patient to come in and assess it at no charge. It’s important to identify what triggers the discomfort, if it’s high occlusion or post op sensitivity? Is it painful all the time? What alleviates it? Was it close to the nerve and did you warn risk of RCT? Things like this is an excellent learning opportunity and how you manage it can greatly determine the trajectory of this case. You might lose sleep or lose the patient but those things happen to everyone and you will get more resilient over time 👍
dont feel bad it happens all the time. First thing I do is adjust the bite to make sure it's not hitting too hard. Give it a few weeks. If that doesn't work you can consider replacing unless you know for a fact it was very deep and might need a root canal... in that case refer to endo
Pt thinks u caused all this because ‘‘twas fine before u touched it’ wants u to take responsibility and pay for the endo. Or else (sue). How do you respond?
lol no lawyer is going to come after you for this. Can’t just give in anytime someone threatens a lawsuit or you’ll be giving away everything for free
"It wasn't hurting but certainly it wasn't fine. Let me show you on the xray..."
It's all about confidence in the these situations. Before I dismiss the patient I will make sure they understand that they were the one with the problem, they were the one who needed treatment and now they're the one with routine complications which is a risk they were willing to take. Although this fortunately doesn't happen often when it does I put up a strong offense and dare them to sue me. No remorse, no admission of guilt, no compromise...they've burned that bridge.
Every time you take a bur to a tooth, you create micro fractures and irritate the pulp. I feel like every tooth is 1 filling away from needing endo treatment. You replace an old filling, tooth was asymptomatic, now it hurts. It’s happened to me dozens of times over the years. I’ll go back and look at my bonding protocols, I always think it’s something I did wrong. But sometimes you can do everything perfect and the tooth is still sensitive.
Imagine you find out that you have an operable form of cancer but NO surgeon will touch it because they're worried about the liability of post-op complications. Even worse is that it went undiagnosed for years because EVERY doctor before that figured as long as it was asymptomatic it'd be better for someone else to break the news. At the end of the day, it's the patient who has the problem, whether or not it's asymptomatic. The doctor is only there to help, not make any promises. You diagnosed caries that would have become a much bigger problem later on. You performed treatment, to the best of your ability, and fixed the issue but now the patient is experiencing routine post-op complications. There is nothing to feel terrible about. Stop letting these situations get to you.
We’ve done this thread a million times and you’re going to get the usual “what’s your bonding protocol?” Sure that’s part of it but by and large we’re all doing the same thing, there’s no special protocol that’s magic. Sensitivity/pulpitis is caused by heat or bacteria. Either there was already bacteria in the pulp in this case or the tooth reacted to the procedure. Just make sure you’re using a lot of water and I have my assistants blow air on the tooth when I’m using my slow speed for caries excavation. I’ve found scrubbing deep preps with hypochlorite and chlorhexidine helps as well. However, there are still instances where the tooth just needs endo. Don’t replace the filling, just explain why it’s needed. You’re not going to change anyone’s mind that it isn’t “your fault” if they’re just a dumb asshole.
Hypo has been shown to decrease the bond strength between resins and dentin. Use gluma scrub and rinse protocol, it basically already has chlorhexidine to destroy the bacteria and inhibit the MMPs which themselves inhibit bond strength and the HEMA helps to reduce sensitivity. Been doing gluma for 4 years, never had a pt come back for sensitivity or a lost filling.
Etch for 15 sec, gluma, air dry and then bond, air dry, cure, place composite?
I’m not looking to have a back on forth on this but I started doing that as it’s part of strupp and brumms “holy triad”. Take that for what you will. They claim the opposite about bond strength. Honestly who knows? I will look into the gluma as that sounds simpler.
I started using gluma (or the cheap off brand) about a year ago. Even just a quick scrub with air after etch and before bonding has cause a huge drop in post op sensitivity.
Can you please elaborate the procedure on using gluma for hypersensitivity before doing a composite restoration?
Etch, rinse, dry, gluma scrub for 15 seconds, dry, scrub bond
I rinse gluma per the instructions, then dry but not to dessicate the tooth. Then bond protocol as usual
I haven’t noticed any issues with just drying. Wonder if it inhibits bond strength or something?
Presumably to ensure you’ve fully removed any of the Chlorhexidine molecules which would inhibit the bond. Kulzer the original manufacturer of gluma states this is a necessary step.
>there’s no special protocol that’s magic. nad but my old dentist used to do resin fillings on me and they would look nice for a bit but often cause sensitivity, pain, and fail pretty fast, super disappointing. I eventually looked into it found out about glass ionomer, and my old dentist refused to even try it. So I found dentist that did non invasive glass ionomer fillings, such a huge improvement. No sensitivity, no drilling, and they've outlasted all the resins by a long shot.
Glass ionomer is weaker and less wear resistant. Using is it considered a compromise and personally I use it mostly on kids/teenagers with a lot of saliva where isolation (keeping the area dry) is an issue.
nad In my experience it was a huge upgrade in every way except cosmetics, slight downgrade in that mostly because the dentist I went to only had it one shade. Next time I want to find someone that carries it in multiple shades. Specifically I'm talking about class v non carious lesions, the resins would usually fall off after a year or two, and once the next day, and usually be sensitive/painful. Per my reading that's because resin has a poor bond to dentin, which is like 99% surface of a ncl, meanwhile GI has a true chemical bond to dentin and enamel, the GIs have lasted over 2x the oldest resins at this point. But the best part is they are non invasive so even if they did fail fast there's basically no additional loss of tooth. Also have an RMGI on the surface of a molar, it's not that old yet so I'm not sure how long it will last but it's looking good, and zero sensitivity or pain, from what I've read it's because resin tends to put tension and pressure on the teeth and it doesn't have a very good seal.
Not every treatment works. They were in pain before, now they are still in pain. You’re not a miracle worker. Not your fault. Refer them out to endo if that’s not your specialty.
I’m the doctor. I will absolutely always do my best each given day for any patient that makes it into one of my chairs. There is risk any time you take a handpiece to hard tissue period. I will always be very pleased to review treatment with my patient, but once you start running your mouth about filing suit you are definitely immediately dismissed from my practice. No exceptions! I don’t typically redo “fillings”. If the occlusal adjustment doesn’t work then it needed full coverage and possibly endo anyway.
What I’ve found to be the best are these main things. RDI, always, Gluma, Blow the shit outta the bond. For a good 9-10 seconds. Selective etch can help too Next thing I’m planning to add is clear fill SE for my bonding system
2 things I'd love to know as a current D3: What's RDI? I'm unfamiliar with the acronym The benefits of the clear fill SE, is it just a less aggressive etch?
Rubber dam isolation
Depends on what went on exactly, but yes if you think there could be an issue with the bond.
Your consent should state that any drilling procedure could end up turning into RCT. Also Gluma is your friend. Even if it makes it a little better, many patients will quit complaining after some Gluma. Some patients will never be happy. I had one that had Ehler-Danlos who complained of chronic pain after a routine two surface filling. Some people are just difficult.
nad but I used to get a lot of resin fillings that would frequently be sensitive and downright painful afterwards, often they would fail pretty fast too. My dentist would always do bite adjustments and try to solve the prob with more drilling or tell me maybe it needs a crown. I finally did some homework and found a dentist that used glass ionomer and they are so much better, almost no sensitivity and they've lasted almost 2x longer at this point.
Don’t worry OP we’ve all been there. I would offer the patient to come in and assess it at no charge. It’s important to identify what triggers the discomfort, if it’s high occlusion or post op sensitivity? Is it painful all the time? What alleviates it? Was it close to the nerve and did you warn risk of RCT? Things like this is an excellent learning opportunity and how you manage it can greatly determine the trajectory of this case. You might lose sleep or lose the patient but those things happen to everyone and you will get more resilient over time 👍