September 2001 – Complications of Coronal Leakage

Fig. 1	Fig. 2

September's case of the month deals with a previously virgin maxillary left cuspid bridge abutment. A 63 year old male in good health arrived in my office complaining of diffuse toothache with localized sensitivity to palpation over the cuspid apex. The tooth had been prepared as a bridge abutment during the past year. The tooth displayed symptoms of necrosis. Pulp tests performed on #23 showed no responses to heat and cold. The periapex showed PDL thickening and I suspected loss of pulp vitality. (Fig.1) A cavity test confirmed my suspicions, the pulp was non-vital. Endodontic treatment was initiated and completed in one visit. (Fig.2)

There is no question that preparation of previously heavily restored teeth can cause eventual necrosis. But why would a conservatively prepared virgin cuspid ( properly prepared with water spray) become non-vital so quickly? Could it have something to do with the restoration itself? Closer examination of the crown margins revealed the answer. The labial margin was grossly deficient and had been filled with cement that had washed out. (Figs.3-6)

Fig. 3	Fig. 4 Open margin with cement
Fig. 5 - Profile view of margin	Fig. 6 - End of #5 explorer under margin

1. Protection of the Patient's Endodontic Investment
   Grossly inadequate restorative treatment such as this places the Endodontist in a very difficult position. Besides contributing to the initial canal necrosis, these open margins will ultimately result in eventual recurrent decay and possible "wash out" of the abutment, canal recontamination and the need for endodontic retreatment. Therefore it is the responsibility of the Endodontist to point out such deficient treatment when it occurs, if only to safeguard his own treatment and to protect the patient's investment. The real difficulty is how to do this without causing embarrassment to the referral.
   
   
2. Informing the patient of the need for restorative remake - The big dilemma
   This problem is one of the biggest liabilities of having a referral based practice. There is no question that the Endodontist has a legal and ethical responsibility to ensure that the patient is fully informed regarding his condition. This includes any deficiencies in other treatment that may directly contribute to the success or failure of the endodontic treatment just provided. ( E.g./ Perio problems, restorative deficiencies) . However, if the patient must be informed that the margins are deficient, the Endodontist should speak directly with the dentist about the problem and let the referral inform the patient. This situation must handled cases such as this with tact and diplomacy. There is no point in phoning the referring dentist and berating him for what is obviously substandard care.What should be emphasized to the referral is that this kind of treatment will result in eventual endodontic treatment failure and that "patching" the margins with composite is not enough. Yes, it does mean that the referring dentist will probably have to pay for remake of the bridge ( at least the lab costs) out of his own pocket. He will also have to explain to the patient why the bridge needs to be remade so soon after initial cementation.
   
   
3. The need for good communication with the referring dentist
   The most important factor in successful resolution of cases like this is good communication with the referring dentist. A rapport must be established that places emphasis on the ultimate goal...the best possible treatment outcome for the patient, rather than any deficiencies in previous treatment. This means that egos must be put aside and that occasionally frank discussions must take place. The good referral understands that the Endodontist wants the best treatment outcome and does not take these "suggestions" personally. Referrals who "prescribe" endodontic treatment without accepting treatment plan recommendations of the Endodontist should recognize that this is not in the best interest of the patient. Unfortunately, when endodontically treated teeth become symptomatic, it is often the Endodontist that is left to explain the problem, even if it is not Endodontic in nature ! The buck stops in his office. For that reason referrals need to work together with Endodontist as a team, rather than thinking of the Endodontist as a clinician who merely "dispenses" endodontic treatment without regard to the patient's overall needs and treatment plan.

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