What would you do?

124 Rating(s).


Posted on By Sergio Rubinstein In Periodontics

72 y/male has advanced periodontal problem on upper right second molar.
While the tooth must be extracted and has advanced bone loss, furcation involvement and class III mobility, he can not have any invasive surgery for
1 year due to a hearth condition and medication!
Welcome your thoughts


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20 Comments

Hi! I don't know his heart conditions at this very moment, but I don't if having that chronic infection it is better or worse than the "trauma" of an extraction when mobility is class III....
I would personally try to talk to his doctor (cardiologist) and discuss about the issue, after working for several years in a Hospital in quite sure he will agree to do the extraction although in a Hospital or similar.
Interesting case that may come to any of our offices!
Thanks for sharing!
Jose Mompell


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Thanks for you input! Extraction is not an option! The cardiologist was very firm about not having anything invasive after the hearth attack, cannot stop or reduce blood thinners for 10-12 months!


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While other factors may pose contraindication, the blood thinners are normally not an issue especially for a single simple extraction.


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Is he in pain, what are his symptoms? Willing to bet lesion has been there for a long time? Have a similar situation. No pain, just lesion on radio graph. There is always endo. What did we do. Called physician, explained problem, he said antibiotics and remove the tooth. We removed the tooth. If CA is not an issue get another opinion, or leave until patient is in pain.
bb


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Do not have available old radiographs, but I do agree this problem has been around for a while! Periodontist was aware of it for a few months and wanted it extracted; but once the patient saw the cardiologist, he did request "at all cost", do not extract the tooth for 1 year"!
While the Periodontist insisted on taking it out, patient did seek a second opinion and that is when I saw him!
Quite upset at the Periodontist for insisting on removing the tooth while the Cardiologist requested not to(if at all possible).


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No pain or even discomfort!


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Thanks for your input!


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Hello,
Here in the UK,we don't tend to alter the medication regimen for patients with INR below 4. So,if there is nothing else,i would definitely extract these teeth, one after the other.
Regards
Todor


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I would recommend the INR to be 3.0 or less and the extraction should be safe for the patient. The patients can clot it just takes longer so adjust the post-op instructions for more time with pressure on the socket. Elective procedures are delayed for 6 months in patients that had an Myocardial Infarction(MI). Most cardiologist I have worked with will clear the patient 6 months after the MI.


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I appreciate your comments! As a general
rule, I do not as a dentist over ride a
cardiologist decision. The doctor knows
this tooth could be a source of bacteria
traveling to the heart and it is in no
way a stable condition and one way or
another must be managed!


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What other thoughts are you looking for?
Ideally the tooth should be extracted.
I seriously doubt any heart condition or medication would preclude treatment for a year. Even the recommended time frame for treatment after an MI is 6 months.

But, when dealing with patients with medical conditions I also defer to their physician, cardiologist, etc.
CYA
There may involve a large eye-roll when I do hear their recommendations, but once the recommendation is there I wouldn't normally override it.

How would you "manage" a patient that doesn't get work done that you recommend?
All you can really do is watch and wait.
He's not in pain? Watch and wait.


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I guess u can offer an atraumtic extraction via usage of ortho separation rubberbands on the whole tooth if it's cone shaped or via separation of the roots and doing it on every root on it's own,
Similar to what has been done with extractions on patients in risk of osseonecrosis(bronj).

Just a work around worth exploring..
Here is a link..
https://link.springer.com/article/10.1007/s00198-012-2239-8
Good luck
Aryeh


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1 year later, this was the treatment provided:
1) Antibiotic, Amoxicillin 2 gram 1 hr/ prior to each cleaning
2) Local anesthetic, scale the tooth(in this case, practically
all the way to the apex). Patient applied Peridex 2x a day
on the distal
3) Occlusal adjustment
4) Splint both molars.
5) Root canal treatment, only with calcium hydroxide,
changed 4 times.
6) Repeat scaling session w/ anesthetic every 6 weeks.

Buccal view of the splint
Occlusal view after the root canal


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Tooth to be extracted in 1 month.

Final radiograph
Inversed radiograph


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That treatment provided seems a hell of a lot more "invasive" that extracting a class III mobile tooth with practically 100% bone loss.


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So how would you manage the medical situation if there are any complications during the extraction?


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Zero pain, no surgical intervention, no sinus complications and bone on the apical portion was gained!
Patient never left the office with any bleeding.
Is this area better off now than 1 year ago?
Were the original goals achieved? Dentally and medically!
My answer is YES!


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Great conservative results Sergio. I like your splinting and root canal therapy. Much better results than an extraction and i think those molars will last some years more. Congrats!


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Thanks for everyones input and comments! Patient is having tooth extracted and bone graft this month!


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I LIKE it a lot Sergio. Thinking OUTSIDE the box for sure!! thanks Mo


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Omnia