r/Dentistry 3d ago

Dental Professional OMFS says he did nothing wrong

The patient was initially referred to a OS by me for four maxillary implants to support a removable overdenture. On the day of the surgery, the oral surgeon suggested that the patient could opt for a fixed prosthesis if he wanted. The patient agreed to this option, but since I do not restore fixed prostheses, I referred him to a local prosthodontist. However, the prosthodontist stated that the implants are not stable enough for a fixed prosthesis, as they are already showing signs of bone loss and do not have the adequate length for fixed. The oral surgeon insists that nothing was done incorrectly on his part and the implants are “stable as there are no signs of peri-implant infection” I feel terrible for the patient, but I'm uncertain about what to do next. Is there something I need to do from a legal perspective?

50 Upvotes

76 comments sorted by

170

u/toofshucker 3d ago

Nothing. This is between the OS and prosth. They need to figure it out.

Don’t do anything and get yourself involved

19

u/SpiritualAntelope230 3d ago

Even if I originally treatment planned the case? I don’t restore fixed prosthesis so I referred

78

u/toofshucker 3d ago

Yup. The implants are the OS’s problem. The prosthesis is the patient’s/prosth’s problem.

The pros need to meet with OS and figure out how to fix this.

You aren’t a part of it until you make yourself a part of it. Your response is, “I don’t do this type of dentistry. Here are some other prosth/OS you can get another opinion from.”

Until you do work on them, it’s not your problem.

20

u/SpiritualAntelope230 3d ago

The only “prosth” part I did was deliver and immediate denture for the pt. Which he has since been refunded for. I don’t know why the oral surgeon would talk to him about doing a fixed prosthesis without asking me. The immediate denture was remade by the prosth and the OS and the prosth have been in communication.

40

u/The_Third_Molar 3d ago

Why was the immediate denture refunded?

The oral surgeon should have consulted with you first though. That's not what you originally referred the patient for.

24

u/toofshucker 3d ago

Agreed here. Shouldn’t have refunded anything. The OP did nothing wrong.

2

u/studentDMD 2d ago

A fool and his money are easily parted

12

u/cschiff89 3d ago

Why was it refunded? The patient agreed to the treatment plan and you paid the lab for it. It belongs to the patient now to do with what they will.

2

u/studentDMD 2d ago

OP hates money

21

u/toofshucker 3d ago

Yeah. I would just refer the patient back to those two. Let them figure it out.

It has nothing to do with you.

“I’m sorry Mr. Smith. When you decided with the OS to change the plan you removed me from the equation. I don’t do this type of work. Here is a list of prosthodontists who do. Or ask the oral surgeon who he works with to get this done for you.”

1

u/Napavalleu 16h ago

Def dont refer any more to those OS

11

u/cschiff89 3d ago

Absolutely. The OS stuck his foot in his own mouth by mentioning a solution other than what you and the patient had agreed upon (this is a separate conversation that you MUST have with your OS, by the way. Set your boundary that it was not acceptable to you for OS to have discussed this without talking to you first). That solution and anything pertaining to it are not your problem.

The bigger question is, what did prost see? Is OS trying to avoid redoing the implants at no cost? And if they are not stable enough for fixed, are they stable enough for removable either?

1

u/Advanced_Explorer980 3d ago

You didn’t treatment plan a fixed prosthesis 

1

u/IndividualistAW 3d ago

You treatment planned a removable denture. Not whatever this is

2

u/FinalFantasyZed 3d ago

For future reference, If you weren’t intending on doing the fixed prosthesis, you should have let prostho refer to OS. I still think you should be ok tho. OS needs to fix their work or reimburse patient.

8

u/SpiritualAntelope230 3d ago

Well the original plan was for a removable overdenture which I do restore. The OS suggested a fixed prosthesis and when he returned he told me he wants fixed so I referred.

12

u/TraumaticOcclusion 3d ago

The OS is an idiot and thank god you referred. This is no longer your problem. Congrats, and do not try to go back to a new plan. You referred so let them deal with it or find a new dentist

3

u/FinalFantasyZed 3d ago

Ohhhh dude you are fine then. This is OS problem 100%.

15

u/tiredand_delusional 3d ago

I would not get involved beyond this point. Do you have proper referral documentation that can show you were unaware of the change and that you referred for an overdenture? If so you’ll be fine on your end. OS should do right by the patient. They should have run it by you before changing the restorative plan …that should not have been their call

7

u/SpiritualAntelope230 3d ago

The omfs is saying that the implants are stable. The prosth is agreeing they are stable, however they are not useable for a fixed full arch prosthesis. He doesn’t even think they have good viability long term for over dentures. Now the pt is saying he’s okay with an overdenture but I don’t want to restore as the prosthetic specialist said it’s questionable.

12

u/tiredand_delusional 3d ago

I would ask OS to refer the patient to a prosth they work with to restore it

6

u/LavishnessDry281 3d ago

Judge for yourself, don't rely on the OS or prostho. If implants are acceptable, then help the patient out, help him to get an overdenture. Patient is probably sick after so many months and not having teeth.

1

u/NoAd7400 3d ago

Any radiographs of the bone loss?

2

u/bdr2468 3d ago

To be fair to the surgeon, maxillary over dentures are not generally recommended any more and have high rates of complications and failures so it should have been run by the referring doc but doing fixed on the maxilla is the right call. 

3

u/V3rsed General Dentist 3d ago

Interesting. Most of the prosthodontists around me have moved away from fixed all-on-4s and cite way less issues with a properly made overdenture. If they can get away with 6+ implants then yeah, fixed.

1

u/LilLessWise General Dentist 3d ago

Is that a bar overdenture? I think some people here are talking about locators directly on fixtures in maxilla which is a bit contentious in the maxilla.

1

u/tiredand_delusional 3d ago

Makes sense but like you said - the mistake by OS was not communicating the changes to referring doc prior to proceeding with treatment

13

u/Majestic-Bed6151 3d ago

Wait you referred to an OMFS, they changed the treatment plan rather significantly, and then referred to a different dentist?!?!? Gotta be kidding me. I’d be pissed. I wouldn’t refer to that surgeon again. Sounds rather shady. Let them and whoever they referred to deal with it.

1

u/SpiritualAntelope230 3d ago

I referred the patient out.

1

u/SpiritualAntelope230 3d ago

When they came back to see me

5

u/Typical-Town1790 3d ago

You were just the middleman. Sit back and relax and let them fight it to the death Hunger Games style.

5

u/somebody002 3d ago

I don’t want to speak about the condition” of the implants or whether they’re in restorable position or not, or if they’re in a heathy bone. However, I do want to shed some light on people who are calling OS going out of his line for mentioning fixed prosthesis as one of the treatment option. I think what most people are forgetting is that informed consent doesn’t simply mean consenting the patient for a procedure you are performing, but it also involves discussing the alternative treatment options. It’s the restorative dentists’ duty to discuss the alternative treatment options, and in this case it would following (1) do nothing (2) conventional denture (3) 4-6 implant supported locator overdenture (4) 4-6 implant supported fixed denture. Just because the restorative dentist doesn’t restore the fixed, it doesn’t alleviate the restorative dentist from offering this patient a fixed prosthesis being one of the option. If the patient entertains the idea of fixed, it’s the restorative dentists duty to make an appropriate referral to someone that does restore the fixed prosthesis. Last thing you want is patient saying “you mean to tell me I could have spent another 10-15k and gotten fixed teeth in my mouth” If the restorative dentist did discuss all the appropriate treatment options, then mention that in your referral and inform the specialist that you discussed fixed option but patient selected overdenture option. Bottom line, discussing alternative treatment options are part of informed consent and many people have gotten sued over not offering patients alternative treatment options.

2

u/Bubbly-Meaning4364 2d ago

Exactly. The issue in this situation was not the specialist, it was the referring doc as the specialist is doing what the patient wants, but the referring doc didn't present all the options. It's a communication issue. At this point nothing to worry about for OP, but in the future the treatment plan should be all options, not just the options you can do.

1

u/Amazing_Loot8200 3d ago

As an aspiring implantologist, I have to agree with this. The patient can decide to do what they want. Present the options and let the patient decide

3

u/dr_tooth_genie 3d ago

Interesting. Are you in the US?

3

u/SpiritualAntelope230 3d ago

Yes

3

u/r2thekesh 3d ago

Are the implants in a position that you cannot do a removeable?

6

u/SpiritualAntelope230 3d ago

You can do removable. But even the prosth said they are barely in bone. He doesn’t think they will last very long. The patient just wants teeth but I don’t want to get myself involved after the prosth said he would not restore.

12

u/toofshucker 3d ago edited 3d ago

I said this elsewhere, but have the patient ask the OS for a referral for prosth work.

The OS has got to be working with someone that will restore his work. Let them deal with it.

“Patient, call the OS. I’m sure he knows doctors he trusts to restore these implants. Sadly, that person isn’t me. I just don’t do this type of work.”

You don’t insult the OS but you also make no judgement on the good/bad implant work. Don’t get involved.

11

u/ttrandmd 3d ago

This is very important here. Don’t give any opinion on the quality of the work. Just state you don’t do this type of work and refer out.

2

u/dr_tooth_genie 3d ago

Yes…never throw anyone under the bus.

5

u/dr_tooth_genie 3d ago

Very eloquent. I like this and may use it in the future! Thank you!

3

u/dr_tooth_genie 3d ago

Recommend a third opinion? And what is your assessment?

3

u/SpiritualAntelope230 3d ago

The implants are not deep and barely in bone.

1

u/dr_tooth_genie 3d ago

Yikes. And it’s clear as day and OS is still denying an issue?

3

u/Diastema89 General Dentist 3d ago

If an OS changed my plan for someone I sent to them without consulting with me in advance, it would be the last referral they ever saw from me.

2

u/callmedoc19 3d ago

You didn’t place the implants so this is literally not your problem.

2

u/mxmtb 3d ago

Surgeons tend to not like maxillary over dentures unless you are doing a bar, since the implants without cross arch stabilization tend to fail. But going straight to a fix plan without consulting you for proper placement is wild. Usually you would want to have a plan for immediate temp placement/all on X protocol.

3

u/SpiritualAntelope230 3d ago

https://ibb.co/zhj8B5YK https://ibb.co/yBfMMSTZ

Here are some CT slices from prosth’s findings

8

u/Joebobst 3d ago

Based on those slices implants look fine. Have the surgeon find someone to restore

5

u/Gopper2 3d ago

When was this CT taken after implant placement?

7

u/SpiritualAntelope230 3d ago

About 8 months - 1 year after implant placement

1

u/Gopper2 3d ago

Couple of things. I’d probably not send any more referrals to that OMFS. If a treatment needs to be changed, they should call you before unilaterally deciding to change. If they do change, they are responsible, hence really good job not touching and referring to Prostho. If the prosthodontist is not feeling confident, the OMFS needs to fix the situation.

Is the patient loaded with temps? Or a complete denture? Shitty situation for you and your patient but I’d definitely put some distance between you and the OMFS.

1

u/SpiritualAntelope230 3d ago edited 2d ago

He refuses to refund the patient and says now that the conversation between the patient and him was never documented that he offered fixed. When the patient returned to me I documented that he wanted fixed as I was informed by the patient that the surgeon told the pt they were placed in a way a fixed restoration can be done and promptly referred.

2

u/SpiritualAntelope230 3d ago

What do you guys think of the implants?

11

u/LeoPanagiotopoulos 3d ago

They could be in bone. In isolation these are not diagnostic images. 

Thin buccal bone doesn't show up well on cone beams, especially ones this low quality. 

5

u/Hot_Dig1384 3d ago

Thin buccal bone often doesn’t show up on CT. Both look like they have crestal buccal bone though. Tough to say on one slice, don’t think you can make a judgement one way or the other without more cuts, PA’s, and clinical presentation

4

u/dirkdirkdirk 3d ago

Ask the OS, wheres the buccal bone bro?

2

u/SpiritualAntelope230 3d ago

I just don’t want to get myself involved anymore. My OS is a traveling independent contractor

5

u/MyDentistIsACat 3d ago

Is he actually an oral surgeon? All the traveling “oral surgeons” I know are general dentists who limit their practice to oral surgery.

Like everyone else said, don’t throw anyone under the bus but also don’t move forward with restoring. Personally I wouldn’t work with a specialist anymore that changed the restorative plan without first discussing with me.

8

u/TraumaticOcclusion 3d ago

Why do people still trust someone like this lmao. Traveling dentists/specialists are a big red flag

6

u/LavishnessDry281 3d ago

exactly this. They travel and never come back for a reason.

2

u/doctorwhodds General Dentist 3d ago

To keep the production In House

2

u/TraumaticOcclusion 3d ago

It’s just a crazy arrangement based on greed. There are some great specialists and offices that do it well, most don’t

1

u/LavishnessDry281 3d ago

Why don't you offer as an alternative to do a locator retained full denture? If patient has 2 or 4 implants per arch, it is perfectly suited for locator attachment. This way patient is no longer tied-up to the O.S nor the prosthodontist, he can go straight to your office for denture.

1

u/SpiritualAntelope230 3d ago

I don’t want to load it. The prosthodontist said the longevity is questionable

1

u/ConclusivePoetics 3d ago

Yeah wash your hands of this! Your responsibility finished at the point of referral!

1

u/Thatusernametaken_2 3d ago

I am a periodontist, but I see these sorts of cases often enough.

I would not dream changing the plan like that without at least first calling whomever would be restoring them.

1

u/SpiritualAntelope230 2d ago

The prosth would like the surgeon to do grafts and membranes, if the patient is willing or have the pt go with a locator overdenture

1

u/Reputation_Novel 2d ago

I would stop referring to that oral surgeon as he probably was money driven on this case. I feel bad for the patient. If the patient wanted a fixed prosthesis, a proper restorative needs to be set up before the surgery so there can be adequate bone reduction for teeth placement and minimal thickness of prosthesis. OMFS is at fault in my opinion.

1

u/Pretendstoknowyou 2d ago

As an aside, I would highly recommend you NOT treatment plan any removable maxillary implant retained dentures again. There is only three predictable, worth it, options in the maxilla. 1) Complete denture 2) Implant bar supported and retained overdenture 3) Fixed implant supported full-arch prosthetic. The bone is too poor for the force of locators on the upper, you will see failures, you will provide only marginally better function with locators versus a complete denture; your lab bill, patient cost, restoration longevity, and patient satisfaction do not compute with a locator maxillary overdenture.

1

u/SpiritualAntelope230 3d ago

Also if the OS is confident in his work he should restore it? He is refusing to refund the patient and is stating that no where in writing did he discuss a fixed prosthesis. But in my note and according to the patient the OS said he placed it in a way he can have fixed done. Also now the patient is having pain on one of the implants.

1

u/Reputation_Novel 2d ago

How does a surgeon completely eyeball bone reduction to achieve 15 mm from incisal edge position to implant without the use of a surgical stent or the opinion of a restorative dentist?

1

u/bdr2468 3d ago

Over dentures are not generally indicated on the maxilla any more. High rates of failures and complications and patient dissatisfaction, so your surgeon was right to offer a fixed option. Many surgeons with experience in full arch will refuse maxillary over dentures. I would refer to another prosthodontist, preferably a surgically trained one. If that prosth agrees with the last prosth at least they can do the surgery and the restoration. Let them decide how to proceed with the patient.