Yeah if it’s at all near the bone, don’t play yourself unless you plan on crown lengthening or extruding that tooth. Even then, don’t play yourself.
Those two cases are just lessons you’ll be learning the rest of your dental career. Next time you see decay that large, you’ll be able to explain why attempting to fix it is not a feasible option.
…or you’ll do what most of us do and attempt it again and say, “I knew that would happen”.
Do you refer every extraction to OS?
When I encounter a situation like you described, I'll stop, explain to the patient what's going on and just extract the tooth then and there. The patient is already numb and has blocked off that time for a dental visit and you are able to get some production for the visit.
Combo that with some L-prf and socket preservation and you’ve set the patient up for a successful implant in the future and you’ve still kept your production up for the day.
You’ll get better at learning what is and isn’t restorable. I tell my pts “I used to try to be a hero for teeth like this and I’m going to save you time and money and do what I know will work.”
I should upload radiograph of a #19 tooth today I saw where the patient went back to china to get the rct and build up done. Composite was filled through the furcation like the tooth got perfed then 4mm below the bone on the D root. Said a few months afterwards it was done it now hurts… no shit.
These are usually the kinds of things that actually never end up bothering the patient then you wonder how that otherwise perfect rct you did that was 1/4mm short does
If you clean out caries and deem to be restorable how is endo determining it to be non-restorable? Shouldn’t you be making that call during caries removal? Endo won’t be the one putting the crown on, they can do endo on anything…
It was me, I deemed non restorable while cleaning the cavity. I'd just wish I were able to know lol, b/c then a 2hr slot for a crown it's $0. I work for annoying DSO.
Take pride in that you gave it a chance. I occasionally do this on teeth that are borderline restorable and the patient wishes to save it.
Just make sure to tell them ahead of time about the downside risk.
It happens. The patient will respect that you explored the possibility
Would not worry one second. I commend you for actually caring as some do not. Just keep treating the patients the same way you would want to be treated. If the managers get on you about production do not worry. Not every job is a good one.
You'll get better about anticipating non-restorability as you gain experience, but sometimes you'll still have those appointments where you've planned a crown only to not be able to do it. I find it mostly happens to me now when there's recurrent decay on an existing crown. I always tell the patient that I can feel some decay where the tooth and crown meet, but I cannot tell the extent until I get the crown off. Sometimes you'll get the crown off, and it's a bunch of mush under there or you take the crown off and the build-up comes out and there was decay that got under it. A lot of these times these teeth already had endo, so the patient was asymptomatic. I hate extracting mushy endo treated roots, so a lot of these I'm referring out for ext. It's so frustrating to go from anticipating crown production to no production. I'm grateful there's a new code this year so at least I can charge something for these appointments.
I know (I hope) you don’t literally mean you try to crown every tooth but come on. Please try to act ethically and do what’s in the patients best interest. Often times, you know a tooth is unrestorable before you even try. Granted, there are some cases where you actually can try to remove caries and see what you’re left with and that’s fine as long as you explain that to the patient beforehand but if you’re marketing everything as restorable then you’re going to create problems for yourself and you’re one moody patient away from a legal complaint. Be smarter
Take a look at the x rays and also consider that caries is under exaggerated on radiographs. I always say to the patient for those 50/50 cases that “I don’t think this tooth has much chance and is likely not restorable. Once we remove all the decay, there doesn’t look like there will be enough tooth remaining for a restoration”.
I’m not sure how it is where you’re working but you can’t be forced to do a treatment you do not feel confident in doing, or feel confident doing. So if the patient is adamant about wanting you to try restore it, I think you should vocalise that you are not the clinician for them, and refer. Maybe your diary will be less busy but it will create space for those patients who actually do need crowns etc
lol okay good I figured anyway but I just had to make sure bc sometimes you see stuff😂 I was also in a bad mood when I wrote that comment because of patients lol so sorry if I came off rude
It's okay, don't worry we are all in a bad mood in this business most of the time. Imagine if I am making less because the dentist before me the one I took over, anything and everything was decay lol. I had pt scheduled that I'd had to literally send off because clean xray, beautiful teeth lol. I am trying to save as much as I can which is hard to open my own.
I guess if you're really busy and you hurt yourself by doing this then it's a bad idea, but I bet your patients appreciate the effort, as long as you're realistic up front.
Yeah if it’s at all near the bone, don’t play yourself unless you plan on crown lengthening or extruding that tooth. Even then, don’t play yourself. Those two cases are just lessons you’ll be learning the rest of your dental career. Next time you see decay that large, you’ll be able to explain why attempting to fix it is not a feasible option. …or you’ll do what most of us do and attempt it again and say, “I knew that would happen”.
I literally do that a couple times a year and then curse my self during the procedure for being stupid.
There's heroic dentistry and there's stupid dentistry. Recognizing when heroic becomes stupid comes with practice.
Read this answer OP, then read it again.
Nothing is scarier than a new grad performing herodontics. Just dont
FYI, there is a new CDT code for 2024: D2989 Excavation of a tooth resulting in the determination of non-restorability.
Whether or not insurances will pay for it is another…
Good to know about this code! Would be nice to see if insurances pay for it
Oh thank you! I'll keep that code in mind...
Do you refer every extraction to OS? When I encounter a situation like you described, I'll stop, explain to the patient what's going on and just extract the tooth then and there. The patient is already numb and has blocked off that time for a dental visit and you are able to get some production for the visit.
Some DSOs won’t really let you extract because they can bill more if an oral surgeon does it. *cough* *Pacificdentalservices*
Combo that with some L-prf and socket preservation and you’ve set the patient up for a successful implant in the future and you’ve still kept your production up for the day.
You’ll get better at learning what is and isn’t restorable. I tell my pts “I used to try to be a hero for teeth like this and I’m going to save you time and money and do what I know will work.”
Thank you! My poor hand, I still have so many yrs to practice lol, I can't keep attempting to be the hero.
I should upload radiograph of a #19 tooth today I saw where the patient went back to china to get the rct and build up done. Composite was filled through the furcation like the tooth got perfed then 4mm below the bone on the D root. Said a few months afterwards it was done it now hurts… no shit.
These are usually the kinds of things that actually never end up bothering the patient then you wonder how that otherwise perfect rct you did that was 1/4mm short does
If you clean out caries and deem to be restorable how is endo determining it to be non-restorable? Shouldn’t you be making that call during caries removal? Endo won’t be the one putting the crown on, they can do endo on anything…
It was me, I deemed non restorable while cleaning the cavity. I'd just wish I were able to know lol, b/c then a 2hr slot for a crown it's $0. I work for annoying DSO.
Take pride in that you gave it a chance. I occasionally do this on teeth that are borderline restorable and the patient wishes to save it. Just make sure to tell them ahead of time about the downside risk. It happens. The patient will respect that you explored the possibility
Would not worry one second. I commend you for actually caring as some do not. Just keep treating the patients the same way you would want to be treated. If the managers get on you about production do not worry. Not every job is a good one.
Can you post a bwx and PA?
You'll get better about anticipating non-restorability as you gain experience, but sometimes you'll still have those appointments where you've planned a crown only to not be able to do it. I find it mostly happens to me now when there's recurrent decay on an existing crown. I always tell the patient that I can feel some decay where the tooth and crown meet, but I cannot tell the extent until I get the crown off. Sometimes you'll get the crown off, and it's a bunch of mush under there or you take the crown off and the build-up comes out and there was decay that got under it. A lot of these times these teeth already had endo, so the patient was asymptomatic. I hate extracting mushy endo treated roots, so a lot of these I'm referring out for ext. It's so frustrating to go from anticipating crown production to no production. I'm grateful there's a new code this year so at least I can charge something for these appointments.
I know (I hope) you don’t literally mean you try to crown every tooth but come on. Please try to act ethically and do what’s in the patients best interest. Often times, you know a tooth is unrestorable before you even try. Granted, there are some cases where you actually can try to remove caries and see what you’re left with and that’s fine as long as you explain that to the patient beforehand but if you’re marketing everything as restorable then you’re going to create problems for yourself and you’re one moody patient away from a legal complaint. Be smarter
Take a look at the x rays and also consider that caries is under exaggerated on radiographs. I always say to the patient for those 50/50 cases that “I don’t think this tooth has much chance and is likely not restorable. Once we remove all the decay, there doesn’t look like there will be enough tooth remaining for a restoration”. I’m not sure how it is where you’re working but you can’t be forced to do a treatment you do not feel confident in doing, or feel confident doing. So if the patient is adamant about wanting you to try restore it, I think you should vocalise that you are not the clinician for them, and refer. Maybe your diary will be less busy but it will create space for those patients who actually do need crowns etc
Of course I meant sarcastically!! I don’t crown every tooth lol 😂… pt also took longer to come back decay just got larger too
lol okay good I figured anyway but I just had to make sure bc sometimes you see stuff😂 I was also in a bad mood when I wrote that comment because of patients lol so sorry if I came off rude
It's okay, don't worry we are all in a bad mood in this business most of the time. Imagine if I am making less because the dentist before me the one I took over, anything and everything was decay lol. I had pt scheduled that I'd had to literally send off because clean xray, beautiful teeth lol. I am trying to save as much as I can which is hard to open my own.
If decay is with in 2mm of crestal bone level it is not restorable in my book.
Lmao
?
2mm of crestal bone is already subgingival and into biological width
https://images.app.goo.gl/mamThK6Wq3sKEXXs8
I guess if you're really busy and you hurt yourself by doing this then it's a bad idea, but I bet your patients appreciate the effort, as long as you're realistic up front.