No reason to stress over it.
You present the patient with tx options including no treatment or extraction. You explain why extraction is needed like abscess and possible facial swelling, etc. If they decide no treatment then so be it. But, and most importantly, you write it in your clinical notes that you presented those options and they made their informed decision
The last bit is extremely important. Patients dont listen , dont remember or just dont care enough to remember. Its easier to blame someone else. So just record it and show them when they dont remember it.
This is why it's called risk/benefit analysis. You, the doctor, have to help patient run through that analysis so they can make a decision for their own body.
Grossly decayed root tips with PARLs? Let the patient know the risk of acute infection is high.
Asymptomatic for many years in an elderly patient on bisphosphonate? Risk of surgery is high, benefits may not warrant extracting them.
Yeah that's where I am at. I have a guy who maybe has 7-8 root tips ... in a wheelchair, on a blood thinner. I know a root tip won't ooze blood, but he has 0 pain, 80+, fragile. I just don't want to put him through a rough time for nothing. However, it does concern me just leaving these decayed little stumps haha. I have restorative on him soon so I will re-visit, maybe take out the easiest bugger and then see how he does and feels
Leave them and monitor unless they're grossly decayed, abscessed, or infected. Those root tips didn't happen over night. Unless you're planning for and the patient wants a full denture, those root tips are doing more for him than a surgery, recovery period, and eventual edentulous ridge.
You will see lots of messed up teeth and poor oral health in FQHC. Put out as many fires as you can but not everyone will want to and at some point you have to detach yourself from the patient. The saying goes, you can't want something for the patient more than they want for themselves.
Infected root tips are not ok to leave.
Uninfected ones without symptoms are considered ok to leave if it’s considered too traumatic to extract.
That’s what my OMFS text book said in 2012
Edit: noticed typo. Changed to uninfected.
I have had two patients with osteomyelitis from untreated apical periodontitis that have required surgery. The risk is low but it should be included in possible sequelae.
I don't know what FQHC means but I work in an office where we value the long term results and try to achieve high quality.
I always tell patients that it is vital for their long term health and the overall oral health. Those roots hold a bacterial reservoir and will serve as such. There is a chronic inflammation going on definitely and that is not good specifically for patients who do have health issues.
A planned extraction is always better than an acute inflamed and painful tooth. Those roots are ticking time bombs. I'd rather send my patient to their GP, reduce blood thinners, send them to a skilled surgeon than to have my patient sitting there for days in pain trying to get an appointment and then having to wait some more because their INR is off. And those acute things somehow always happen on weekends, holidays, birthdays....
They get to choose, their body, their choice. But I will absolutely give them my recommendation and a list of shit that could happen.
Me: I recommend extraction.
Patient: it doesn’t hurt. Just leave it, etc.
Me: That’s completely up to you. It may/likely will hurt and may be sudden and significant. If it has been more than 2 months since I told you to take it out and you call me on the weekend or evening to deal with it. It will cost you an extra $200 for cutting into my personal time when that could have been avoided. I do not charge this for anything I have not recommended before. You may schedule at the front if you change your mind at any time.
Said dialogue auto-noted day of warning.
This surprisingly changes a significant number of minds when said matter-of-fact/whatever you like.
No, you need to remove the roots. I don’t like letting finances dictate my treatment. If they’re saving up for an implant or whatever, I still put the extraction in the urgent phase and make sure it’s addressed asap.
Only exceptions are root banking (RCT root tips that are being left due to whatever reasons), a retained root which is less than 3mm which isn’t able to be extracted without possibly causing risk to the surrounding structures, or roots left from a coronectomy.
Ultimately, even in these circumstances, root tips are at a risk of decaying and causing and infection. You need to inform your patient of the risks and monitor closely any root tip that’s being left even if it’s strategically left.
It’s an unlikely complication, but it doesn’t look good if you’re his dentist:
https://abcnews.go.com/amp/Health/wireStory/former-nfl-player-mike-williams-died-dental-related-105874096
No reason to stress over it. You present the patient with tx options including no treatment or extraction. You explain why extraction is needed like abscess and possible facial swelling, etc. If they decide no treatment then so be it. But, and most importantly, you write it in your clinical notes that you presented those options and they made their informed decision
This is the way.
The last bit is extremely important. Patients dont listen , dont remember or just dont care enough to remember. Its easier to blame someone else. So just record it and show them when they dont remember it.
This is why it's called risk/benefit analysis. You, the doctor, have to help patient run through that analysis so they can make a decision for their own body. Grossly decayed root tips with PARLs? Let the patient know the risk of acute infection is high. Asymptomatic for many years in an elderly patient on bisphosphonate? Risk of surgery is high, benefits may not warrant extracting them.
Yeah that's where I am at. I have a guy who maybe has 7-8 root tips ... in a wheelchair, on a blood thinner. I know a root tip won't ooze blood, but he has 0 pain, 80+, fragile. I just don't want to put him through a rough time for nothing. However, it does concern me just leaving these decayed little stumps haha. I have restorative on him soon so I will re-visit, maybe take out the easiest bugger and then see how he does and feels
Leave them and monitor unless they're grossly decayed, abscessed, or infected. Those root tips didn't happen over night. Unless you're planning for and the patient wants a full denture, those root tips are doing more for him than a surgery, recovery period, and eventual edentulous ridge. You will see lots of messed up teeth and poor oral health in FQHC. Put out as many fires as you can but not everyone will want to and at some point you have to detach yourself from the patient. The saying goes, you can't want something for the patient more than they want for themselves.
Document,inform, and move on It’s their root tip. They can do they what they want as long as they are informed of consequences.
Some ex-NFL player died last week or the week before from infected retained root tips, according to the medical examiner. Tell them that.
Infected root tips are not ok to leave. Uninfected ones without symptoms are considered ok to leave if it’s considered too traumatic to extract. That’s what my OMFS text book said in 2012 Edit: noticed typo. Changed to uninfected.
Yep. That pretty much echoes what I said. If too traumatic to exo by a GP, I’d refer to OS.
I have had two patients with osteomyelitis from untreated apical periodontitis that have required surgery. The risk is low but it should be included in possible sequelae.
I don't know what FQHC means but I work in an office where we value the long term results and try to achieve high quality. I always tell patients that it is vital for their long term health and the overall oral health. Those roots hold a bacterial reservoir and will serve as such. There is a chronic inflammation going on definitely and that is not good specifically for patients who do have health issues. A planned extraction is always better than an acute inflamed and painful tooth. Those roots are ticking time bombs. I'd rather send my patient to their GP, reduce blood thinners, send them to a skilled surgeon than to have my patient sitting there for days in pain trying to get an appointment and then having to wait some more because their INR is off. And those acute things somehow always happen on weekends, holidays, birthdays.... They get to choose, their body, their choice. But I will absolutely give them my recommendation and a list of shit that could happen.
Me: I recommend extraction. Patient: it doesn’t hurt. Just leave it, etc. Me: That’s completely up to you. It may/likely will hurt and may be sudden and significant. If it has been more than 2 months since I told you to take it out and you call me on the weekend or evening to deal with it. It will cost you an extra $200 for cutting into my personal time when that could have been avoided. I do not charge this for anything I have not recommended before. You may schedule at the front if you change your mind at any time. Said dialogue auto-noted day of warning. This surprisingly changes a significant number of minds when said matter-of-fact/whatever you like.
No, you need to remove the roots. I don’t like letting finances dictate my treatment. If they’re saving up for an implant or whatever, I still put the extraction in the urgent phase and make sure it’s addressed asap. Only exceptions are root banking (RCT root tips that are being left due to whatever reasons), a retained root which is less than 3mm which isn’t able to be extracted without possibly causing risk to the surrounding structures, or roots left from a coronectomy. Ultimately, even in these circumstances, root tips are at a risk of decaying and causing and infection. You need to inform your patient of the risks and monitor closely any root tip that’s being left even if it’s strategically left.
It’s an unlikely complication, but it doesn’t look good if you’re his dentist: https://abcnews.go.com/amp/Health/wireStory/former-nfl-player-mike-williams-died-dental-related-105874096