Why am I experiencing clinical failure?
Posted by: Dr. John Cranham
If we've been practicing for any length of time at all, we're going to see some clinical failures. I think sometimes the perception is if we're faculty at The Dawson Academy, that it never happens, and you should know that we all see clinical failures. We just want to limit them as much as possible, and so there's really going to be two reasons that something fails.
Simple biological failures
The first is biologic failures.
This can be from not doing our restorative dentistry at the detail that we would like. So maybe we don't get our margins quite the way that we need to, and that can be because of preparation issues, or retraction, or poor impression techniques.
It may be just not having a good diagnosis, in terms of the periodontal conditions that are going on. But what I find is most of those clinical failures happen earlier in our career when we're gaining reps. I think that if we're paying attention, we work hard, and we follow the principles that we learned in dental school, we can really limit that.
Failures from force management and occlusion
The second type of failure that we're going to see that I think frustrates us the most has to do with force management or the occlusion; These are situations like porcelain breaking, crowns or veneers de-bonding, spaces opening up around teeth. All of those things are related to not having good control of the occlusion. So a lot of what we teach at The Dawson Academy is for our students to recognize, first, occlusions that are unstable to begin with and then give a formula where we can apply Dr. Dawson's principles of occlusion to gain stability before we start doing the restorative dentistry.
The importance of recognizing instability before doing treatment
It's very logical that if a patient starts with a functionally stable occlusion, that we can do crown and bridge on it and have good success. But if we start recognizing the signs of instability, such as wear, mobility, migration, sore muscles, TMD issues - and one of the first things we should do after getting the mouth biologically stable is to get the occlusion functionally stable. And once the occlusion is functionally stable, then we can do our prosthodontic treatment with great degrees of stability.
Biological issues from old age
The third thing that you might see also is in the biologic realm, but it can be very frustrating. You may see patients that you did restorative dentistry on many, many years ago, and now the patients are getting older, and they're on lots of medications, and their mouths are dry.
I've been in practice now nearly 30 years, and this is one of my points of frustration where I'll see these patients towards the end of their life losing their saliva, and they start getting decay around restorations that have been stable forever, and that's a tough one.
So starting to employ techniques in your practice where you can really help them with increased fluoride and maybe chlorhexidine rinses two weeks before their cleaning to try to alter some of the bacterial count can by very helpful.
Pay close attention to the small details
So I think if you really start paying attention to the details of your just nuts-and-bolts restorative work, and your big cases, and getting really good, clean margins, good protocols for periodontal treatment prior to the restorative phase, starting to really employ good occlusal therapy into your cases, which we certainly can help you with, and then have a protocol in place for some of the high caries risk patients, that can really decrease the number of failures you see in your practice. So anyway, hope that helps.
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