Children’s Hospital Los Angeles CTICU, Entry #4

*Please note that newer entries for my personal blog are published in reverse order (newer posts are published at a later date), so that the true story of my family can be told in chronological order. The real date of this post is October 31th, 2011*

To no surprise, I did not sleep well that night … it didn’t seem to help the fact that I had to go to work on that next day. I remember going through the motions of my daily routine and going to the office. Everything felt so surreal almost like I was living a really bad dream. Walking around like a zombie with a numbness crawling up my brain and down my fingertips. Just waiting … or rather, hoping for someone – anyone to pinch me and wake me up.  All I could think of was getting through the day so that I could go over to Children’s Hospital after work to see my baby girl.

By the time I got out, it was a little past 7 o’clock. My wife had called me; she was in pain from her cesarean and wanted me to come see her at Huntington Memorial. So I quickly jumped into the car and drove straight to the hospital. I arrived to see my wife in bed, looking very haggardly – I’m sure my tired body didn’t look much better. She was in pain and had a hard time trying to do daily activities. The nurses at this so called 5 star hospital were of little help – they would make my wife try and do things on her own, even though every step she took her stitches would open and fluid would hemorrhage out of her incision. I remember my wife looking at me- we were both really tired, I was torn between leaving my wife alone here and running off to see my sick daughter. I could tell my wife was concerned with how tired I was and afraid that I would fall asleep and get in a car accident on the way to see my daughter. I called the cardiothoracic intensive care unit and children’s hospital in Los Angeles.  The nurse there said Hanna was stable and that my sisters and mother had visited her that day. I think the nurse could tell how tired I was; she recommended that perhaps it would be better that I came early in the morning since it was already getting late. I finally succumbed to my weariness and the advice of my wife and the nurse, I would get some rest that evening and head out early morning to see Hanna.

I was up early the next day. Had some breakfast at the hospital, made sure my wife was okay and was off to Children’s Hospital LA. Upon arriving at the hospital, I checked in at the front and had them look up where my daughter was. The receptionist said she was in CTICU and made a call up there to verify that I was authorized to go up. Apparently they only allow 2 people up in that unit. Once I got the okay, I walked through and up the elevator. The place was rather large, lots of signs and different departments. There were many pictures on the wall with children experiencing various congenital heart problems. They had their birth dates … and their demise date. Some only lived a few weeks, many only a few years and others passed away at their teenage years. I could feel a pit starting to form in my stomach and refused to read any further. I immediately went up to the cardiology department counter and asked to see my daughter. They asked me to wait in the waiting area because one of the cardiology specialists wanted to speak with me.

Fifteen minutes later, I was escorted into one of the exam rooms to the side and met with Dr. Ahdoot. He was very patient with my flurry of questions. Currently Hanna was on PGE1 to keep her PDA open and she was on back up life support. Normally he would not have gone into so much detail because most parents would not understand the extensiveness of the surgeries and or the complications of my daughter’s heart condition: hypoplastic right ventricle with tricuspid valve dysplasia.

Once I understood the severity and risks of my daughters defect, everything that I experienced from the past few days finally crushed me like a ton of bricks. I could not bear the weight and ramifications of my daughter’s condition … of the fact that our daughter may not live past her first surgery … and that IF she survived the first, there would be many more major surgeries to follow … after which I feared she would never be that healthy, bright and happy girl that I had always imagined. I kept thinking how it was so terribly unfair for a parent to out live their child. Unable to hold back the wave of emotions, I crumbled down, a flood of tears washed down my face as I somberly cried for perhaps the first time in 18 years.

Dr. Ahdoot handed me some tissue and offered some words of encouragement. He told me a story about a good friend of his, who was also a pediatric cardiologist. That doctor was born with a similar congenital heart defect. His friend was in his late forties and continues to treat children with similar congenital heart defects like Hanna’s. He also pulled out a picture in his email, showing a family who moved up North, who had a daughter also with a similar heart defect. She was currently doing well at the age of seven. More importantly he showed me that the couple had three other healthy children in their family. I realized that life still goes on and that there was still hope for my daughter.

After my meeting with Dr. Ahdoot, I was then escorted to CTICU to the room where Hanna was resting …

* Too be continued *

The Truth about White Fillings

On a weekly basis, I seem to always have at least one conversation with one of my patients in regards to white fillings. Just recently in July, I had someone ask me why their old white fillings done by their prior dentist were failing. Meanwhile some of their old silver fillings that were done during their childhood were still going strong. In order to address the questions that many people may have in regards to white fillings, I have decided to compose a brief explanation:

White fillings in general have a life expectancy of 2 to 25 years, while silver fillings will usually last anywhere from 15 to 30 years. The reason there is such a wide discrepancy between white fillings is because these fillings are very technique sensitive. In addition there are also many types of white filling materials and bonding agents that may be used by the dentist. Silver fillings on the other hand, are far less technique sensitive and there is basically only one type of silver filling material.

When determining the life expectancy of white fillings, the hand skill and technique level of a dentist are typically an unknown and always a changing variable. The patient has no real control over the proficiency of the dentist at the time of service. However the type of white filling and bonding agent is a constant and more controllable variable because of the vigorous lab and in-vitro testing done in order to get these dental materials on the market.

The longevity and strength of a white filling material is determined by numerous factors. However in order to simplify, I have listed two very important attributes: Polymerization shrinkage and Compressive Strength. Please keep in mind that each white filling material will measure up differently for each category. Better numbers in shrinkage rate will not always result in better numbers in compressive strength and vice versa. It is up to the dentist to determine the best material with the attributes that will provide the best results for each individual case.

The polymerization shrinkage rate is measured by a percentage. The lower the shrinkage rate, the lower the chance of a cavity developing under the white filling. Basically a lower shrinkage rate translates into a longer lasting white filling. The shrinkage percentage can range from as low as 1.4 percent to as high as 5 percent. Again the lower the percentage the better the material.

The compressive strength measures the ability of the white filling to withstand the forces of mastication and grinding. The higher the compressive strength, the less likely the white filling will be crushed when chewing and grinding with the teeth. This attribute is measured in MPa and can range from 100 to 500 MPa. The higher the number, the better the material.

Now the type of bonding agent will determine how well the white filling bonds to a tooth. The stronger the bond, the longer the white filling will last. This bond strength is also measured in MPa. The bonding strength to enamel can range from 10 to 38 MPa. While the bonding strength to dentin (the inside portion of a tooth) can range from 5 to 44 Mpa. Again the higher the MPa, the better the bonding agent. However, just because a bonding agent has a stronger enamel bond, may not mean it will have a strong dentin bond and vice versa – it is up to the dentist to determine which agent will work best in each case.

There are over a hundred different kinds of composite material and over fifty different kinds of bonding agents. Typically the better the material, the higher the cost. In addition every few years new materials and bonding agents are introduced – so a dentist must keep up to date, if they wish to provide the best level of care.

That being said, I typically will explain to patients that we use the best bonding agents and white filling materials on the market and we will constantly change these out for better products regardless of the cost on a regular basis. We also use a variety of different bonding agents and filling materials depending on the type of cavity or tooth we are working with. We always try and choose the best material for each case. I spend hundreds of hours every year doing research on all our dental materials. Most dentists have no clue as to how their material rates up against others. There are some dentists who will only use the dental material that gets them the best bang for their buck or the material that they had used long ago in dental school – this in essence will lead to more failed white fillings.

As of today, the white filling material that we use at our dental office has a polymerization shrinkage rate of 1.48 % and a compressive strength of 500 MPa. Our bonding agent has an enamel bonding strength of 35 MPa and a dentin bonding strength of 44 MPa.

Memories about Children Dentistry

In early June, my staff and I attended a continuing education course on treating children who have extreme fears of dentistry. It was titled “Little People, Big Problems.” Because I see a lot of children in my practice, I thought this course would be excellent for learning new tips. Sitting in that course brought back some memories from the past. As part of the staff at the USC dental mobile clinic in 1999, I did charity work for under-privileged children all over California. I remember we would have to sterilize and set up treatment rooms in make-shift clinics – most of which were cafeterias or auditoriums and elementary schools. We would then  have to  treat over 500 kids in one day. At the end of those busy days, I always felt exhausted both mentally and physically, but just seeing those happy innocent smiles on so many children made it all worth it.

At the end of the course, my staff had commented that they felt as if they learned “nothing.” I explained to them that because of my extensive experience with sedation and working with children, I had trained them on many techniques for working with kids. Apparently, the course was geared towards those dentists who were having “Big Problems” with children – which did not apply to my staff and I. Even though we may not have learned anything new, I still feel that it is important for my staff and I to attend these types of courses. Without sitting through these lectures, there is no real way of knowing if new information would have helped our practice. As dental professionals, in order to provide the best level of patient care, I feel we must continuously make every attempt to learn and improve ourselves in all aspects of dentistry.

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