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TOWNIE CLINICAL: Direct composite provides transitional treatment for patient with limited resource By: Jason Luchtefeld, DDS

More by this author (3)
A 61-yr old female, presented with several failing amalgams (fractures and/or decay. A few teeth required extraction. In our discussion about treatment options, she wanted to save her teeth and replace missing teeth. The patient only had $117 left on her insurance and could not afford to pay any more at that time to restore her teeth with crowns. I’ve been too nice a guy about ‘loaning’ money so I offered her an interim treatment plan of a large filling on tooth #30. I thoroughly explained the future potential for a root canal/crown vs. extraction if the decay went too deep and the consequences of this approach. The patient is very financially strapped right now, wants to save her tooth and was extremely thankful for this affordable opportunity. Details of this restorative case are shown to the right.


Photo 1: DB view
Photo 2: Note distal decay, overhangs


Photo 3: Prepped
Photo 4: Full Tofflemire (dead soft band) in place to place flowable in boxes


Photo 5: Flowable is in boxes, Tofflemire removed, Composi-Tight gold in place. Short ring on mesial, tall ring on distal
Photo 6: Immediately after removal of Composi-Tight. (Yes, I have a lot of trimming to do...maybe that’s why these take me so long?)


Photo 7: Finished trimming, adjusting occlusion, and contacts
Photo 8: Tooth polished and dried

I was happy with the end result and think the case turned out very nice. The patient was very excited about having a nice-looking (and feeling) tooth. In the several months since, she has experienced occasional discomfort to biting very hard. This may mean the tooth is flexing and a crown could be indicated. Ultimately, we hope to crown the tooth when her finances are more stable. I will apply the $200 spent on this tentative procedure to the cost of the crown if we complete the procedure within the next five years. The same is true if she requires a root canal within the next five years—I will apply her $200 as a credit. If the patient requires an extraction, I will perform the service for free for continued goodwill.

Jason Luchtefeld, a very active Townie, graduated from SIU/SDM in 2000. GPR at VA Med. Center in Denver. He opened his solo practice in Frisco, CO, in 2001. He focuses on providing patients with comprehensive care cost effective treatment plans to give them the option of saving their teeth, without being totally dependent on their insurance/financial constraints.

You can contact Jason directly at his Ten Mile Dental practice, P.O Box 2207, 965 N. Ten Mile Dr., Ste A5, Frisco, CO, 80443. His office phone number is 970-668-1010, Fax: 970-668-1005. Dr. Luchtefeld’s email address is: jluchte@hotmail.com.

Townie discussion on Jason Luchefeld, DDS clinical from www.DentalTown.com Case Presentation


tagarwalnc
 5/22/2003
2:23 pm 		Jason, that is an excellent result. How large were your increments? How much time did this take? Was this profitable for you? Why didn’t you do a lab-fabricated restoration?

I think these are fun (sometimes) because I can see a result that I made.


jasonl
 5/22/2003
2:36 pm 		I used Simplicity, Tetric Flow and Simile to restore. Flowable was placed in .5mm increments. Simile placed in 1-2mm increments (sometimes smaller depending on the location). It took 50 minutes from injection to patient paying. I charged $200 (way too low now I know).

If I did a lab restoration it is going to cost me more, I charge more, and the insurance payment is less. The patient had $117 left on insurance and could not afford to pay more at this time. I’ve been a nice guy about “loaning” money too often. So, I did this. I informed her it might break, need RCT, etc. but she was fine with it.


dgcdmd
 5/22/2003
4:41 pm 		Jason, you and JRTmolar are some heroic guys. I seem to have lost the thrill of placing these large buildups. Your clinical outcome seems just fine. I’m curious. Do you really feel these large buildups are a good option? The reason I ask is because many of them (in my own experience, not just those that I have done, but have seen from others) will fail. And the patient will be forced into having something done at that point. I tend to find that doing what most of us would consider terminal treatment (at least partial, possibly full coverage) is, over the long term, a more predictable restoration? Call me aggressive, but I wouldn’t even recommend placing a direct here to a patient. That having been said, your treatment seems to have worked out nicely.

jrtmolar
 5/22/2003
6:18 pm 		Dave, Jason was clear about his intentions of wanting to do an indirect but the pt refusing due to money. I feel this is an indirect case also but are you going to refuse to tx because they can’t afford ideal tx. I do not, I just make sure my time is compensated for. Jason’s fee/time spent in my office is still profitable. I know other offices that range in hourly over head from $250-700, mine is about $100.

balledds
 5/22/2003
7:59 pm 		I am impressed! I learned something from this. I like how you used the Tofflemire and then combined the Bitine rings. This patient has no idea what a service you provided him or maybe he does and that is why he refused the crown. Great job.

doctored
 5/23/2003
1:20 am 		Not everyone can afford a crown or onlay at any given point in time. Glad you don’t let these teeth rot until they need extraction. In my opinion this case would have been much easier for you to manage with the dam in place. The photo’s reveal that the patients tongue was itching to sabotage the process. Isolate and relax. If you don’t believe it you haven’t tried it enough. I won’t work on a posterior mandibular tooth without a dam. It just makes your objectives easier to accomplish.

glennvanas
 5/24/2003
10:20 pm 		Hi Jason: first of all I want to compliment you on your nice result and your pictures of your case. Having said that I think it is almost impossible to do these large comps well on a consistent basis without a rubber dam. There is just too much room for saliva contamination.

More of a concern for me is the premolar adjacent to it…HUGE DECAY. This is going to fail and then a bridge will be needed which is going to be far more than a crown for the first molar. If the patient chooses a partial there will be a food trap on this tooth, which often ends up with decay around the composite. If left alone without replacement then the molar drifts forward and there is a food trap and recurrent decay between the most distal molars. It’s a tough case agreed with obviously a poor OH patient.

I really think your anatomy in the composite is a nice touch and that you did a fine service for the patient for a very low price in my opinion. Just wanted to raise my concerns.

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