Grand Rounds Kick Off with Complex Case

The first Grand Rounds of the academic year on Wednesday, March 12, 2014, offered ethical food for thought. Zara Nensey DMD 14 presented the case of a patient she saw at Fenway Health during her 10-week externship—a 44-year-old woman with dental problems and even more severe personal issues that affected her oral health.

“This case is a good example of a patient who has dental and non-dental problems,” said Dr. Carl McManama as he introduced Nensey’s presentation.

Nensey’s patient had moderate dental health and brushed and flossed meticulously. She complained of difficulty chewing and had a symptomatic tooth #4.

Her dental health had been on the decline, however, since a serious accident five years before that left her facing more immediate health concerns; she developed PTSD and fibromyalgia and now takes daily medication for constant pain.

The patient’s constant pain made her self-reporting unreliable and Nensey’s job that much more complicated. How could her patient identify what caused her tooth pain and the exact location when she was heavily medicated and in constant pain throughout her body?

Add to that list of challenges a smoking habit, past alcoholism, and limited finances.

The patient’s smoking sparked conversation among faculty attending the presentation. Dr. McManama pointed out the catch-22 of the situation: smoking leads to a need for implants, but implants are far less successful in smokers. Is it worth placing an implant in such patients, faculty asked? Overwhelmingly, they agreed that encouraging this type of patient to quit smoking before placing implants is the most responsible option.

The second major topic of discussion was: How far do you go to save a tooth with questionable prognosis? Would you keep or extract tooth #4?

In this case, Nensey saved the tooth. But the discussion proved how many factors go into making the “right” decision as a dentist.