I'm a newbie to the clinics...Ok, so I had a type 3 perio pt. with some bone loss posterior to #15. In our perio consult, the dr. I was working with told me to tx. plan an ext. on it. I tried explaining to my pt. that it needed to come out (but I didn't really have a good explanation of why). The instructor I was working with would've looked at me ******edly if I would've asked a question like that. It wasn't all that much of bone loss behind it on radiograph, and it appeared to me that it would hold up for a while. It wasn't mobile. I don't understand why a tooth like this would need to be extracted so early, can anyone explain this? Thank you!
how to explain this to pt?
- Thread starter SUSANA123
- Start date
- Joined
- Sep 26, 2010
- Messages
- 159
- Reaction score
- 65
Fascinating question, as it illustrates so much about the, well, flaws in dental education. I have several answers:
-Furcation, furcation, furcation. Perhaps there was bone loss exposing the furcation enough where the prof saw that long term prognosis was poor. For many reasons, a surprising number of them having to do with the root canal system and the accessory canals that are pervasive in molars, periodontal treatment is less successful in furcations than anywhere else on a tooth.
-The overall treatent plan. Would this #15 be asked to stand as a bridge abutment? Single crowns are one thing, but basing a bridge on a questionable tooth is a far bigger risk. Or are implants, or removable, planned?
-There is, however, a wide range of, shall we say, aggressiveness in the decision of when to extract a periodontally involved tooth. My partner and I have taken a very non-aggressive approach to this over the years, as long as there is no demonstrable health risk to our patient and no major treatment plan all depending on such a tooth. Most of our periodontists work with us this way too. I've never experienced any real problems from this approach. Yes, perio is a site-specific disease, and one site can affect others, at least in theory. But we get more aggressive in treatment if the disease is aggressive, and this is relatively rare. It's all about the biofilms and their control anyway...
-What I find upsetting is your prof's attitude towards learning. Not that s/he is speaking to us directly here, but from what you say, there seem to be barriers to asking questions. This is unacceptable! On their part, not yours, I mean. If I was running a dental school, which no one would ever let me do because of all the things I'd screw up, but if I was, one of the things I'd get right is to have a universal signal that students could use when they had a question that they'd rather not ask in front of the patient, which is often the case.
Here's how it would work: when any student gave that signal, the prof and student would go off, perhaps to "get supplies" or some such, and the student could ask their question with absolutely no chance of the professor denigrating them for asking it. All questions fair, no questions considered "stupid" or any such thing. Patience and respect the order of the day.
Consider the advantages. One, students would learn a heck of a lot more from clinical faculty, as there would be no imtimidation as you describe above. Two, students would be trained, day in and day out, to answer patient's questions in the same manner. As it is, arrogance and high-handedness promotes arrogance and high-handedness, unless students make a conscious effort to fight it. Which I'm sure many of you do, but you must have seen clasmates that, by third year, are already strutting around like tin-plated martinets and treating their patients the same way they've been treated by their instructors.
Do some schools have a system like this? I believe they do. But not the one I went to...
-Furcation, furcation, furcation. Perhaps there was bone loss exposing the furcation enough where the prof saw that long term prognosis was poor. For many reasons, a surprising number of them having to do with the root canal system and the accessory canals that are pervasive in molars, periodontal treatment is less successful in furcations than anywhere else on a tooth.
-The overall treatent plan. Would this #15 be asked to stand as a bridge abutment? Single crowns are one thing, but basing a bridge on a questionable tooth is a far bigger risk. Or are implants, or removable, planned?
-There is, however, a wide range of, shall we say, aggressiveness in the decision of when to extract a periodontally involved tooth. My partner and I have taken a very non-aggressive approach to this over the years, as long as there is no demonstrable health risk to our patient and no major treatment plan all depending on such a tooth. Most of our periodontists work with us this way too. I've never experienced any real problems from this approach. Yes, perio is a site-specific disease, and one site can affect others, at least in theory. But we get more aggressive in treatment if the disease is aggressive, and this is relatively rare. It's all about the biofilms and their control anyway...
-What I find upsetting is your prof's attitude towards learning. Not that s/he is speaking to us directly here, but from what you say, there seem to be barriers to asking questions. This is unacceptable! On their part, not yours, I mean. If I was running a dental school, which no one would ever let me do because of all the things I'd screw up, but if I was, one of the things I'd get right is to have a universal signal that students could use when they had a question that they'd rather not ask in front of the patient, which is often the case.
Here's how it would work: when any student gave that signal, the prof and student would go off, perhaps to "get supplies" or some such, and the student could ask their question with absolutely no chance of the professor denigrating them for asking it. All questions fair, no questions considered "stupid" or any such thing. Patience and respect the order of the day.
Consider the advantages. One, students would learn a heck of a lot more from clinical faculty, as there would be no imtimidation as you describe above. Two, students would be trained, day in and day out, to answer patient's questions in the same manner. As it is, arrogance and high-handedness promotes arrogance and high-handedness, unless students make a conscious effort to fight it. Which I'm sure many of you do, but you must have seen clasmates that, by third year, are already strutting around like tin-plated martinets and treating their patients the same way they've been treated by their instructors.
Do some schools have a system like this? I believe they do. But not the one I went to...
- Joined
- Aug 4, 2007
- Messages
- 1,068
- Reaction score
- 8
You can say that again! I had one faculty come up and tell me that a tooth needed to come out. Another came up about 15 minutes later and said that it could last another 10 years with care.
What is the right answer? There isn't one. One member likely based their decision based on the fact that they highly doubted the patient would be able to take care of the remaining teeth that they had because they obviously had a poor history of taking care of their current teeth. The other member based their decision on the true ability of the tooth to be saved based on the best possible scenario of good dental care and high patient compliance. The problem is, neither is right and neither is wrong. The answer is based on your perceptions of what the patient is willing to do and what the best treatment scenario is. E.g.- every case is different.
- Joined
- Mar 10, 2010
- Messages
- 888
- Reaction score
- 4
The best thing to do is give the patient options. No one wants to have their tooth pulled, especially if it doesn't hurt. Maybe ask your instructor what the consequences would be if the patient chose not to extract? Perhaps SRP, a year of perio maintenance, and then re-evaluate?
We had a patient a few years ago with vertical bone loss and an 8mm pocket on the distal of #15 (only slight furcation involvement). We referred her to the periodontist. They opted to do a bone graft which was very successful and she still has that tooth. She has excellent homecare, however.
We had a patient a few years ago with vertical bone loss and an 8mm pocket on the distal of #15 (only slight furcation involvement). We referred her to the periodontist. They opted to do a bone graft which was very successful and she still has that tooth. She has excellent homecare, however.
- Joined
- Aug 20, 2006
- Messages
- 3,923
- Reaction score
- 1,248
Every time I get stressed out when treatment planning, I try to remember what my job is in the scheme of things: it's my job to examine, report my findings, make a diagnosis, and recommend a treatment. If more than one treatment is possible, it's my job to explain the pros and cons of each. Ultimately, the decision rests with the patient. As long as their consent is informed, all that's left to you is to do the best job you can with the treatment they have chosen.
It's not that I don't care; it's actually quite the opposite. I, and many others, allow myself to get too caught up in wanting the patient to choose what I think is the "right" treatment plan and get stressed out if the patient doesn't want to do what I recommend. I don't need that additional stress. As long as I have done my job as well as I can, given the patient all the options with associated information, and follow through with their decision as best I can, then I can feel comfortable knowing I have done my job well. It's not my job to coerce someone to change their minds.
It's not that I don't care; it's actually quite the opposite. I, and many others, allow myself to get too caught up in wanting the patient to choose what I think is the "right" treatment plan and get stressed out if the patient doesn't want to do what I recommend. I don't need that additional stress. As long as I have done my job as well as I can, given the patient all the options with associated information, and follow through with their decision as best I can, then I can feel comfortable knowing I have done my job well. It's not my job to coerce someone to change their minds.
- Joined
- Sep 26, 2010
- Messages
- 159
- Reaction score
- 65
The other aspect of your question is how to explain to a patient that some treatment is ideal when the condition doesn't hurt. This extraction of #15 is such a case, and there are many other times when this issue comes up.
It helps to give examples of other diseases that don't hurt but cause great damage over time, like hypertension and glaucoma. But, then again, human beings are singularly poor at risk assessment, and for every person on blood pressure medication that prolongs their life, there are probably five that haven't had it checked in a decade.
So what can we do?
Go visual. People are trained (unfortunately, in my view) by countless hours of television over their lifespans to be highly receptive to visual stimuli. Ihe Internet is much more interactive than TV, at least potentially, but it also makes strong use of visual clues. We might as well take advantage of that fact, as long as our motives are in the patient's best interest.
The DDG GP iPad app is the most remarkable tool of this type that I've ever seen, especially because it's simple. No Hollywood music and voiceovers like CAESY. You say what you want about the situation; you get to have a conversation with your patient over their diagnosis and treatment. Plus, if the patient is holding the iPad and moving the slider that changes the graphic, while you're both talking to each other, while the image is there in front of them- you're appealing to visual, auditory, and kinesthetic cues all at once. People with strong preferences towards non-visual cues will still "get it".
Only trouble is, DDS GP is $400 when I purchased it. And you need the iPad. Still, there are other apps that do this, even free ones, and of course some of you will say "I'm in for $300,000, what's another $400?" And you're probably right. And if such an adjunct helps you train in presenting treatment well while you're in school, the investment will pay off when you graduate.
It helps to give examples of other diseases that don't hurt but cause great damage over time, like hypertension and glaucoma. But, then again, human beings are singularly poor at risk assessment, and for every person on blood pressure medication that prolongs their life, there are probably five that haven't had it checked in a decade.
So what can we do?
Go visual. People are trained (unfortunately, in my view) by countless hours of television over their lifespans to be highly receptive to visual stimuli. Ihe Internet is much more interactive than TV, at least potentially, but it also makes strong use of visual clues. We might as well take advantage of that fact, as long as our motives are in the patient's best interest.
The DDG GP iPad app is the most remarkable tool of this type that I've ever seen, especially because it's simple. No Hollywood music and voiceovers like CAESY. You say what you want about the situation; you get to have a conversation with your patient over their diagnosis and treatment. Plus, if the patient is holding the iPad and moving the slider that changes the graphic, while you're both talking to each other, while the image is there in front of them- you're appealing to visual, auditory, and kinesthetic cues all at once. People with strong preferences towards non-visual cues will still "get it".
Only trouble is, DDS GP is $400 when I purchased it. And you need the iPad. Still, there are other apps that do this, even free ones, and of course some of you will say "I'm in for $300,000, what's another $400?" And you're probably right. And if such an adjunct helps you train in presenting treatment well while you're in school, the investment will pay off when you graduate.
- Joined
- May 20, 2008
- Messages
- 460
- Reaction score
- 5
The perio faculty at our school are somewhat aggressive. They usually want to extract and place an implant. My unit director sometimes ignores their consults and does amazing stuff to restore the tooth. On the up side our faculty is very accustomed to asking us questions and finding out what our diagnosis and prognosis is before the tell us their decision and the reasoning behind it.
- Joined
- Sep 26, 2010
- Messages
- 159
- Reaction score
- 65
I was at Penn during the Deanship of Jan Lindhe, from Sweden. For the uninitiated, he is one of the world's most brilliant periodontal researchers, a pillar of intellectual honesty, and an amazing human being. I saw him speak back here in the U.S. about two years ago. Everything the man said was amazing, actually, but this statement especially stood out for me:
"We have to ask ourselves the serious question: Do we believe in teeth?"
His answer was a firm "yes" and he and his group have contributed greatly to the knowledge base in treating periodontitis. He also has extensively studied dental implants. particularly the issues with the loss of buccal bone (which is avascular bundle bone and very prone to recession at the slightest provocation). So- like I said- intellectually honest. An example to us all.
Implants are amazing. I place and restore them myself, and have two in my own maxilla to replace congenitally missing #4 and #13, after my primaries finally failed. Yet it all leaves me wondering, considering the literature and the successes in clinical practice of "believing in teeth", and how many teeth are in fact salvageable over long time periods, about these many aggressive periodontists in schools and practice. Why are they so in favor of Titanium Tossing instead of managing the disease they were primarily trained to treat?
What you students have to do is filter. Take in the literature and form your own conclusions. See what works in your hands. Most of all, try to learn the speed at which oral conditions progress. Arrested periodontitis with post-treatment recession looks much the same, in a snapshot in time, as active disease, minus the inflammation. But it may not be going anywhere.
I think some of these aggressive periodontists are hung up on their own opinions. I'm more in agreement with Sherlock Holmes, who, on more than one occcasion, exclaimed, "Data! Data, Watson, give me data!"
Thanks for the replies. They helped alot. I didn't notice any furcal involvement. He didn't have #16, and there were no plans for an implant or any other prosthesis. His opposing occlusion would be fine w/o #15. He was from mexico and never had a professional cleaning, but actually had extremely good hygeine. No cavities and has never been to a dentist. I guess I kind of think "if it ain't broke, don't fix it." But, I am still in the process of figuring out when things need to be fixed or not-- which is why I asked the question on here. And, I agree 100% that the teaching philosophies of some instructors are completely unproductive. It's quite sad. Thanks again for the responses.
- Joined
- Oct 23, 2004
- Messages
- 2,439
- Reaction score
- 68
a lot of dentists have huge egos and an inferiority complex to boot...if unsure, ask other professors about what they think...never stop learning
- Joined
- Oct 25, 2006
- Messages
- 1,801
- Reaction score
- 7
I know it may not be possible, but if you could somehow provide us with a bite-wing, PA, and probing depths we could give you an even better opinion. Otherwise we can't really say much more than what's already been said. Hope you can get a hold of something. I'm curious to see the case.
hippa violation?
- Joined
- Mar 10, 2010
- Messages
- 888
- Reaction score
- 4
Only if the patient's name is on it.
- Joined
- Dec 11, 2004
- Messages
- 11,417
- Reaction score
- 147
A word of advice to the OP. You are in dental school and you are there to learn. No one will spoon feed you the information. It's up to you to make use of the resources given to you. There are hundreds of years worth of dental knowledge and experience under that roof. Ask as many questions as you can. When in doubt, ask. If you are having difficulty with something, get some help. Don't bs your way through school with a goal of trying to graduate as soon as possible. I made this mistake and didn't appreciate the learning environment until I knew I was finishing up my requirements. Once you leave through those dental school doors, it's a scary and intimidating world out there. It'll be just you and the patient in the operatory, you will be the one calling the shots, and you won't get any help there.
- Joined
- Jul 10, 2007
- Messages
- 3,320
- Reaction score
- 3,250
Does this pt have the opposing #18? If the answer is no,then there is no point of keeping #15 epeciallly when it has a severe perio problem.
- Joined
- Apr 6, 2010
- Messages
- 1,571
- Reaction score
- 33
He sounds like a typical perio patient. No cavities but has perio problems. Diff group of bacteria altogether than the ones associated with caries. I'm not sure if it's a good idea to extract #15. It does contribute to mastication, after all... given that #18 is there.
BUT if #18 is missing then #15 would supraerupt over time and serve no real practical function...
I'm also new to the clinics....
Say there is an occluding #18. Since #15 has a deep perio pocket, isn't there a possibility, and likelihood (because it's next to impossible to clean down there) of a perio-endo lesion? When that develops and assuming the patient doesn't want to save the tooth, then isn't extraction much more difficult/complicated? I thought it is hard to give infiltration to teeth with a periapical lesions?
Also, would the other choice be to tx plan: scaling and root planing of #15 with open flap perio surgery, and wait for it to heal, and do a osseous bone graft if the bone level isn't adequate after healing? Why was this never suggested?
Say there is an occluding #18. Since #15 has a deep perio pocket, isn't there a possibility, and likelihood (because it's next to impossible to clean down there) of a perio-endo lesion? When that develops and assuming the patient doesn't want to save the tooth, then isn't extraction much more difficult/complicated? I thought it is hard to give infiltration to teeth with a periapical lesions?
Also, would the other choice be to tx plan: scaling and root planing of #15 with open flap perio surgery, and wait for it to heal, and do a osseous bone graft if the bone level isn't adequate after healing? Why was this never suggested?
- Joined
- Dec 11, 2004
- Messages
- 11,417
- Reaction score
- 147
Doesn't really make much of a difference to your questions.
It really depends on the depth of the pocket and progression of the lesion. It's easier to tell by looking at a PA of the tooth. Do you measure a 10+mm pocket with a radiolucency that is present from the cervival area down to the apex of the tooth? Sounds like it could be a perio-endo lesion (although don't discount a endo-perio lesion or a fracture quite yet).
What you should be concerned about is the infection. The inflammation present will impede the function of the anesthetic preventing it from taking full affect. You can use Carbocaine which works better in areas of inflammation. I won't bore you with the biochemical details. If you still can't get adequate anesthesia despite multiple attempts, just prescribe some antibiotics, and wait a couple days for the infection to calm down and then try again.
Depending on the depth of the pocket and the state of the remaining bone, a bone graft may or may not be successful. We don't know enough about the case to make an adequate diagnosis and tx plan at this time.
N
NAVY DDS 2010
BUT if #18 is missing then #15 would supraerupt over time and serve no real practical function...
This response is to the multiple responses who are discusing this case in case the pt was missing #18. You need to consider two other things before considering removing 15 - does the patient have 17 and 19 and what class of occlusion does the patient have? If patient is missing 17 and 18 and in class 2 occlusion, then the patient will still have 19 opposing 15. If the patient is missing 18 and 19 and is in class 3 occlusion, then the patient wil still have 17 opposing 15. If the patient is only missing 18 and in class 1, it is still possible that the distal margin of 15 will oppose the mesial margin of 17. These situations would most likely lead to preventing the supraeruption of 15.
- Joined
- Aug 31, 2011
- Messages
- 26
- Reaction score
- 2
what is comes down to is this, ... by KEEPING the perio-involved tooth, ... will it affect the perfectly healthy tooth that is adjacent to it...? If it WILL or MAY caue a problem with adjacent healthy teeth, ... pull it out TODAY. PERIOD.
Say that you end up keeping the tooth for many years to come before it acts up with pain....What is the point in saying, ... "yes, .. we got another eight more years of having that problem tooth in the mouth, .. isn't that great? But NOW there is an issue with the adjacent tooth to it..."
Say that you end up keeping the tooth for many years to come before it acts up with pain....What is the point in saying, ... "yes, .. we got another eight more years of having that problem tooth in the mouth, .. isn't that great? But NOW there is an issue with the adjacent tooth to it..."
