do you recommend rct/bu/crown or implant to patients with guarded prognosis on a tooth? for more complicated implant cases, do you have a preference between omfs and perio in terms of referral?
I give patients a choice between rctbucrown and implants. I tend to favor rctbucrown, since when implants go wrong, they can really go wrong and I consider them last resorts for tooth replacements. If implants fail, depending on how they fail, you may not have a second go at it. Especially if you need vertical augmentation. When it's a guarded, poor, or even hopeless, I tell the patient the diagnosis, prognosis, their treatment option(s), and what I would do if it were my own tooth. If they want to try and save a hopeless tooth, I'll try... but I tell them it's a temporary solution that will most likely result in an extraction in the future. Now, some practitioners may say, patient cannot consent to substandard care, but it depends if you're going to treat the hopeless tooth as a definitive treatment or pallative treatment. Patient wants a ridiculously expensive temporary and the treatment plan indicates you plan to extract the tooth later on... You will be surprised how many people love their tooth so much that they are willing to shell out 2500+(rctbucrown,periosurgery) to try and keep a tooth as long as possible knowing I will most likely have to extract. There are some instances where I cannot do anything at all and doing something besides extraction will cause more pain, then I will refuse to do anything besides no tx(medication,pallative tx) or ext. I tell the patient, if I do so and so treatment, you're going to be in more pain than when you first started. In the very least, do no harm... that's where I draw the line. Oh, and no guarantee on the work if they go against recommendation(s). Technically, I never use the word guarantee with the patient. I stand behind my work for 3 years. Anything happens, even recurrent caries, I'll fix it for them. Although I say that if they keep getting recurrent caries, you can only redo it so many times.
In my area, I prefer the perio for referral. The reason is not because of skillsets, but because the perio-restorative team in my area is a lot stronger and more cohesive than the omfs-restorative teams in my region (we always have to have the prosthetic in mind). I refuse to refer to a surgeon who says that it doesn't matter where they place the implants, it's all about the occlusion. I don't do large cases, so I don't mind giving other restorative dentists referrals. However, they have to take the good and the bad... The 50-100k all-on-X cases or immediate dentures/partials. Once I've referred to a restorative dentist or perio-restorative team, the case is all theirs. I don't nit-pick or say that I want to do so and so procedures.
