Where Do You Send Your Patients?

My 45-year-old patient presented to the School of Dentistry walk-in clinic on a recent Friday afternoon to be seen by a dental student. She had driven two hours across the state from her hometown of Grand Rapids. The front page of her medical history included “tumor on C1 Bone,” “tumors in bones,” and “carcinoid tumors in liver and pancreas.” Before I even turned the page to see “carcinoid tumors in abdomen including spleen,” I knew this was not going to be a simple one-hour emergency extraction appointment. On page three, she indicated that the reason for today’s dental visit was “oral cancer, toothache.”

Her general dentist provided us with a well-written and detailed referral. “#18 is grossly decayed, with furcation involvement and associated infection. She is unable to have this extraction in our office because of her current/past medical history and is Metastatic Carcinoid post radiation to the mandible in the area of dental infection.”

I spent the next two hours contacting her primary physician and oncologist to obtain information about her radiation therapy (no easy task on a Friday!). It so happens that she had a 30 Gray course of palliative radiation for her Stage 4 cancer, which was completed roughly a month before.

Once the information was finally assembled, I had a long conversation with the two faculty members supervising the clinic. We all agreed there was no alternative but to extract the tooth because she was in extreme pain and there was no chance for endodontic and restorative success. We had a long discussion with the patient and explained the risk of osteoradionecrosis. She clearly appreciated our diligence and, upon answering her questions, she agreed to the extraction.

A week into my fourth year of dental school, I extracted the tooth. She had driven across the state to have her tooth extracted by a dental student because “she was unable to have this extraction in their office.” It is certainly in our patients’ best interests to refer procedures we are uncomfortable performing, but there is no reason a local specialist could not have seen her.

Sadly, it is common that procedures are referred to the School of Dentistry that can and should be performed elsewhere. We frequently see patients for extractions because the dentist office (which happens to be a dental chain office) “does not have the necessary equipment.” I realize dental equipment is expensive, but a set of elevators, forceps, and a surgical handpiece should be stocked in every office. I have also been told that area dentists have also set up voicemail messages that refer after-hours emergencies to the School of Dentistry.

My not-so-succinctly argued point is that, although it takes a team to properly care for our patients, it is vital that we only refer when it is in our patients’ best interests. Further, we should only refer them to an appropriate provider. When a patient of record shows up in pain, you should be prepared to help him or her. If a case is too complex for your office, it probably should not be sent to a dental student!

Here’s a copy of her pano. What do you think? How would you have managed this case? Do you know a local oral surgeon who would have seen her? Would you have extracted this tooth yourself? Would you have sent her for hyperbaric oxygen? What other precautions would you have taken?

David Coviak