Grand Rounds Provides an Answer: “What do you do if you don’t know what to do?”

March 5, 2013

grand_rounds-patrick_moore-200-v2On February 27, 2013, for the second in the series of Grand Rounds for the 2012–13 academic year, Patrick Moore DMD 13 presented a case that he took on during his 10-week externship rotation at Dental Health Works in Keene, New Hampshire. His preceptor was Dr. Stephen Hoffman.

Professor of General Dentistry Dr. Carl McManama opened Grand Rounds by saying that he wished that the sessions occurred every week rather than a few times a year. Introduced by Dr. McManama, Dean Jeffrey W. Hutter added that “Grand Rounds is among the most important things we do here.”

Attending Grand Rounds and welcomed by Dean Hutter were four students from the University of Hong Kong Prince Philip Dental Hospital—Carrie Kar Wing Tse, Michelle Yu, Law Shuet Wah, and So Stephanie Yuen Ting—who are spending two weeks at Boston University Henry M. Goldman School of Dental Medicine to observe how the School delivers its dental education.

Moore began his Grand Rounds presentation by describing a patient that presented unique treatment challenges. His patient was a 51-year-old man with Down Syndrome whose mother was his lifelong caretaker. At the first visit to the office, the patient’s mother said, “We would like to get [patient name] some teeth.” The patient had had the remainder of his teeth extracted about five months before the visit. He presented with a small maxilla that had  a shallow vault, a large tongue, and palatal asymmetry. He was born with a heart defect that was repaired in infancy and also has Type 1 Diabetes. He has a history of periodontal disease, un-erupted teeth, and severe caries.

Moore was faced with many questions and few straightforward answers. Will simply being in a dental chair pose a risk to the patient? Will he be able to tolerate the time in the chair? What implications do the patient’s conditions have for premedication? Will the patient be able to tolerate the dentures, whether fixed or removable? What about upkeep? What kind of challenges will the differences in muscle posture, bone shape, and tongue size present for implant fitting and cast making?

A textbook would not provide much help in determining a treatment plan for this special needs patient.

As Dr. McManama remarked after Moore’s presentation, Patrick followed a sound piece of wisdom by asking: “’What do you do if you don’t know what to do?’ The answer: ‘Ask someone smarter than you.’” Thus, to come up with a sensible treatment plan, Moore sought the experts and sources of research that would provide insight into the case.

The treatment plan that Moore ultimately established was comprised of multiple phases. The phases were organized so that after the completion of each, the treatment could be suspended if it became too challenging for the patient.

The cast-making for the lower denture presented significant difficulties. Over the process, Moore was forced to abandon a number of endeavors. He was never deterred in his efforts, however. After an attempt to solve the problem by putting together the lower cast from two pieces failed, he achieved success by working with a 3D printer.

Moore then talked about a “learning moment”: As he recounted the instant of “aha,” the dentures were ordered, he was lying in bed in Keene, New Hampshire, when he realized that the asymmetry in the patient’s mouth could be an underlying tooth! He had made the connection between the lesion that recently appeared on the asymmetry and a recently seen patient with an impacted canine erupting under her complete denture.

Indeed, his suspicions were confirmed. Though this posed further challenges, a lesson was learned, the problem was resolved by relieving the denture in that area, and the denture fitting finally took place. The upper denture was a success. Unfortunately, due to the large size of the patient’s tongue coupled with his narrow palate, the lower denture was not well tolerated.

As Moore tells it, at the end of every session with this patient, the patient would pop up from the chair, go straight to the mirror, and smile—hoping to see teeth. Imagine the satisfaction, then, when he went to the mirror and saw a toothy smile. Though the result of Moore’s efforts did not necessarily provide a functional improvement, the aesthetic and emotional improvement is real.

When Moore finished his presentation, Dr. McManama commended him for his work with this exceptional case that presented so many unique challenges. He then opened the floor for discussion. There was a lively debate that included the future role of 3D printing in dentistry, possible alternatives to the treatment plan chosen by Moore, and the presence of a huge underserved population of people with special needs.

Moore had the following to say of his experience with this patient:

While there were a lot of challenges and a few brief moments of frustration, I would say that the dominant emotion while working on this patient was a whole lot of fun. The chance to do something a little out of the normal grind, to work hard, be creative, and think outside the box while providing a service to someone was a real privilege. I really have to thank my preceptor for giving me the autonomy to try something different, and for providing insight and guidance along the way.

While Moore conveyed insights in a number of specific areas of treatment, the overarching message from this Grand Rounds comes in the form of a reminder: While dental professionals may swiftly and easily decipher common problems in their day-to-day practice, there will always remain unique cases that will require intense research, continued education, and persistence.

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