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March 2006 – Offering Reasonable Alternatives When Indicated

This female patient was referred to me for consideration of two asymptomatic maxillary central incisors that had a history of both surgical and nonsurgical endodontic treatment. The canals had been retrofilled with amalgam and presented with persistent small radiolucent periapical areas. There also appeared to be some voids in the more coronal aspects of the canal fills.

The referring dentist was interested in replacing the unaesthetic crowns but was concerned about the prognosis and condition of the endodontic treatment.

After examining the patient I initiated discussions regarding treatment options:

  1. Nonsurgical Endodontic retreatment to include removal of the existing crowns, removal of the existing conventional filling, attempted orthograde removal of the amalgam with ultrasonics, MTA apical barrier placement and attempted conventional refill.  This treatment was definitely pushing the envelope of treatment limits. There was no guarantee that the filling material would not dislodge apically and require surgical removal. Resection of the root and unknown method of retropreparation also created questions as to how well we could get the apex sealed conventionally once the amalgams were removed. Re-cleaning of the canal space would require slight removal of contaminated dentin walls during cleaning and shaping, further weakening the existing root structure. The sum total was expensive, protracted treatment with a relatively unpredictable prognosis.
  2. Surgical endodontic treatment only. This is undesirable because while it addresses the radiolucent apical areas, it does nothing to treat the possibly contaminated canal spaces or coronal voids. Surgery would necessitate additional resection of the tooth, and ultrasonic retropreparation both of which would might further compromise root length and strength. Crown root ratio would also be further compromised.
  3. Crown replacement without endodontic retreatment. This alternative was the least desirable option. While it offered replacement of the restorations, it left the possibility of recurrent exacerbation and possible need for more treatment in the acute phase. The most likely result would probably be extraction after the patient had invested funds in the new crowns. The patient was simply rolling the dice.
  4. Extraction and replacement with 2 implants. This offered a more predictable scenario but financial considerations might rule this out.  The patient needed to discuss the particulars with the referring Dentist.

To complicate the matter further, the patient lived approximately two and a half hours away by car. Should I choose to treat the case would be difficult to coordinate appointments with the referring dentist and the patient could not simply come in a moment’s notice should problems develop.

Can we try to treat this case and salvage these teeth? Yes, we can. It is worthwhile under the circumstances? That is a question best resolved by consulting the referring dentist and the patient. The referring dentist knows the patient (hygiene, financial, psychological and compliance issues?) and is in the best position to help the patient make a choice that best suits their needs. When considering treatment of such a case, we must always be cognizant of the fact that while more exotic or difficult treatment may be possible, it may not be in the patient’s overall best interest. Explaining the options to all parties involved ensures that the right treatment decision for this particular patient is made, while at the same time satisfying the need for informed consent.