CASE: DR. SINGER'S VACATION
Sandra Stuart, a thirty-six-year-old corporate loan officer for a large bank, is experiencing discomfort in the area of a three-unit bridge placed eight weeks ago by Dr. Frances Singer. Ms. Stuart calls Dr. Singer's office and learns from a recorded message that Dr. Singer is on vacation and that her calls are being taken by another dentist whose phone number is provided. But there is no answer at that number, and no recorded message either, so Sandra opens the telephone book and calls the first female dentist she finds, Maria Alvarez, DMD.
On examination, Dr. Alvarez finds that the bridge is loose, as Ms. Stuart had said over the telephone, and that it also has open margins. The gingiva are inflamed both in the area of the abutment teeth and in the pontic area, but there is no inflammation anywhere else in the mouth. She asks Ms. Stuart "Was this bridge permanently or temporarily cemented? Do you know?"
"I had a temporary bridge in there while this was being made," says Ms. Stuart. "When Dr. Singer put it in, it was my understanding that I did not need to come back about it unless it gave me problems, and up until a week ago it didn't. She certainly didn't tell me it was temporary, and I've paid for it completely."
"Then she almost certainly intended it to be permanent," says Dr. Alvarez.
"Is that a problem?" asks Ms. Stuart.
"Sometimes a dentist will cement a new bridge in temporarily to see if there are any problems with it before cementing it permanently. It depends on how the dentist wants to handle it, and both approaches are acceptable. So, there is no problem in Dr. Singer's having cemented it permanently. That is one of the standard ways of proceeding."
"But why is it moving around? If she intended it to be permanent, why is it loose?" asks Ms. Stuart. "And why am I feeling soreness right in the same spot?"
“The gum tissue is inflamed along that whole section," says Dr. Alvarez. "It's very possible that it's the bridge that is causing the inflammation, especially since you do not have any gum inflammation elsewhere in your mouth. I would like to remove the bridge to see if I can figure out what is going on there, if that would be acceptable. I can re-cement it, permanently or temporarily, depending on what I find when I am done. Would that be all right?"
"Yes, please do whatever you think will help," says Ms. Stuart. "I have been avoiding chewing on that side for nearly a week and I really want it fixed. Does it look like it was incorrectly made?"
"A lot goes into making a three-unit bridge," says Dr. Alvarez. "At first look, I think some adjustment of the bridge may help avoid the inflammation. I think it would be better if it fit more snugly under the gum tissue. That may seem strange, but the gums actually get irritated when there is a gap between the bottom of the bridge and the gum tissue, and they are much happier when there is no gap. It is possible that I may be able to adjust that for you right here this afternoon; it is also possible that I may not. First, I need to remove the bridge and see how it is fitted onto the teeth that are holding it in place, in case the irritation or mobility is coming from some cause I haven't seen yet."
"That's fine," says Ms. Stuart, "go right ahead."
Dr. Alvarez removes the bridge and quickly determines that the preparations are nonretentive, conical instead of parallel, possibly overprepared, and the anterior abutment seems too short. It seems very likely that Dr. Singer did not do a very good job on this bridge. It was probably fabricated at a lab rather than in Dr. Singer's office. But even if the fault is in the laboratory fabrication, if Dr. Singer cemented in an inadequate bridge, the responsibility is hers, and there's certainly no blaming the lab for inadequate preparations. What should Dr. Alvarez do about it? Should she tell Ms. Stuart outright that Dr. Singer made a bad bridge? And what should she do clinically, regardless of what she says about Dr. Singer? Dr. Alvarez decides to first find out if Ms. Stuart has been told anything more about the bridge than what she has already said. "Did Dr. Singer say anything more or give you any special instructions about the bridge?" asks Dr. Alvarez.
"Well, she did talk to me about brushing carefully in that area and flossing regularly. I didn't use floss before, but I've been brushing faithfully since I was a kid. So I started brushing in that area more carefully and flossing, too. I don't think I did anything to disturb the bridge though; it just started feeling like it was moving around one day, and pretty soon it started feeling sore there, too. Could I have done something to cause the problem?" asks Ms. Stuart.
This is as good an opening as Dr. Alvarez is likely to get if she wants to get Dr. Singer off the hook. Should she take it, finding some way to make the problem appear to be with Ms. Stuart's self-care? Should she just re-cement the bridge temporarily and tell Ms. Stuart to chew carefully for another ten days until Dr. Singer returns? Should she try to reach Dr. Singer to discuss the case before taking action? What ought Dr. Alvarez do?