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January 2004Treatment Planning for the Patient's Needs

This 53 year old male patient was referred for symptoms associated with the posterior right mandible. The patient had been complaining of percussive sensitivity in the area of the first molar (which had been previously crowned some time ago) and generalized ache in the area. Two films accompanied the patient. The patients' oral hygiene was not good and I noted that I had seen the patient two years previously at which time the maxillary left first molar was deemed too cariously involved to be treated or restored. Extraction of that tooth was recommended at the time.

Fig. 1

The Bite wing radiograph (Fig.1) shows serious Distal decay in the maxillary first molar and suggestion of caries on the distal of the mandibular second molar. The Periapical below (Fig. 2) shows it more clearly.

Fig. 2 - Distal Caries approaching the pulp.

Fig 3. shows the tooth after removal of the occlusal portion of the amalgam. A Mesial-Distal crack is clearly seen under the restoration and extending toward the distal.

Fig. 4

A pulpectomy was performed at which time I noted two significant findings:

  1. The fracture extended down the the distal aspect of the tooth to the distal canal orifice
  2. Caries was seen at a level just above the distal canal orifice. This meant that the restorability of the tooth was certainly in question and that at a minimum, crown lengthening procedures would have to be factored into the restorative equation both as a practical matter and in the way of cost. The patient was made comfortable and the above images were included in correspondence to the referral. At that point the patient was told to return to the referral for further discussions as to whether treatment would be continued.
We can learn several things from this case:

  1. The nature of pulpal pain means that the patient's current complaint is often NOT associated with the tooth to which they may be initially indicating.
  2. Close examination of x ray images is required in patients that have a history of decay in subgingival or unusual areas. That "burnt out" area in a film may indeed be caries and it needs to be examined with an explorer or perio probe.
  3. Does the patient's current Dental IQ, history of postoperative care and financial situation suggest that endodontic treatment and restoration of the tooth is in his best interest?
  4. This tooth also has a complicating factor - the fracture. What is the long term prognosis when we combine this with the crown lengthening procedures that will be required on the distal aspect?
  5. Now that the lower molar tooth is comfortable, would it not be better to remove the crown in the previously treated maxillary molar and determine its restorability? ( This tooth should probably also be endodontically retreated because of the likely loss of coronal seal due to the caries.)

It is impossible for an Endodontist ( who is seeing the patient for just one or two appointments) to make complex treatment planning decisions on behalf of the patient when the referral has not adequately treatment planned the case prior to referral. "Crisis based" treatment planning by the referral is neither effective nor financially efficient for the patient. Unfortunately, it is a simple matter for a specialist to merely complete the endodontics and send the patient back to the referral with the attitude of "you wanted the endo done...there it is...the rest of the patient is not my concern."

Part of the role of the specialist is to educate the patient. Discussion of the consequences of post-endodontic submarginal caries should be an integral part of informed consent. If the referral believes that the patient is unwilling to take the necessary steps to protect the investment of time and effort that has been made on the patient's behalf, then another treatment plan or extraction should be chosen.

In this case the patient requires comprehensive treatment planning and assessment before we can decide whether the substantial funds and effort to rehabilitate this tooth are both merited and appreciated by the patient.