|Case of the Month
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January 2001 – Treatment Planning for Success
||January's Case of the Month features a problem related to Endodontic treatment planning. A 52 year old East Indian male in good health arrived with a history of recent amalgam restoration of #26 and endodontic access in #27. ( The bite wing film fig. 1 shows the case before the emergency access was performed on #27 ) The patient's current complaint was lingering thermal sensitivity in the area after the access had been performed.
Pulp tests performed on #26 showed exaggerated responses to heat and a diagnosis of irreversible pulpitis was made. At this point it seems that the obvious treatment would involve endodontics in both #26 and 27 to be followed by full crown restorations. However, this is not as simple as it seems.
Several factors have to be considered before we initiate endodontic treatment:
- What is the source of the carious involvement ?
- What makes this area prone to decay?
- How do we restore the area to allow the patient to reliably maintain hygiene and preserve his investment?
- Is there an alternative treatment that may provide a better solution?
Examination of the occlusion revealed slightly supra-erupted #37 and chipped distal enamel in #36. The patient also had mentioned prior difficulty with food impaction in the area of #26-27. The cracked amalgam in #27 is a symptom of the stress occurring in this area of occlusion. The large distal overhang is an indication that the restoring dentist had great difficulty in obtaining a satisfactory restorative margin. The distal margin of the amalgam is subgingival and close to the crestal bone.
Although it would have been a very simple matter for me to endodontically treat both teeth and then refer the patient back to the referring dentist, I chose another route. I consulted the referring dentist and asked him if he believed that he could obtain an adequate distal crown margin on tooth #26 under the present circumstances. We agreed that at a minimum, periodontal crown lengthening procedures would be necessary to obtain proper biologic width. Even if we did restore the teeth adequately, without addressing the plunger cusp occlusal problem of the opposing tooth, it is likely that the contact would reopen and the area would again become carious in exactly the same manner. Splinting the crowns together was not deemed an adequate solution because of the difficulty in maintaining hygiene under the soldered contact area. We needed a satisfactory alternative.
We elected to extract #27 and endodontically treat #26. Extraction of #27 eliminates the problem of the opposing plunger cusp and future open interproximal contacts. After removing the second molar we will probably have some gingival shrinkage in the area of the distal margin of #26, so periodontal crown lengthening procedures may be minimal. Removal of #27 will allow for better visualization of the crown margin of #26 during crown preparation. It would also facilitate better oral hygiene by eliminating this difficult interproximal area and allowing the patient to have access to the distal crown margin during brushing. Slight enamelplasty of the opposing #37 may be required for optimal occlusion. The financial cost to the patient is virtually half of the original proposed treatment while the predictability of long term overall success has increased dramatically.
Restorative and Hygiene Factors Must Be Considered in the Treatment Plan
||Simply because a tooth appears endodontically involved, does not always make it a candidate for treatment, referral or restoration.
||Examine the etiology of the problem. Simply devitalizing a tooth with endodontic therapy does nothing to prevent predisposing factors from causing the problem to occur again. This is especially true with poor occlusion, open contacts and inaccessible margins.
||If endodontic treatment is to be performed, the restorability of the tooth must be considered prior to initiation of treatment. All existing decay should be removed and any periodontal considerations (crown lengthening, M-G involvement, minimal biologic width) should be factored into the treatment plan before referral.
||When patients are considering treatment, they must be equipped with all the tools necessary to assist them in making their decision. This includes cost estimates for all potential treatment. In this case, the patient needed to understand the financial and hygiene implications of attempting to salvage both teeth. Ultimately, a compromise (extraction of #27) turned out to be the best treatment plan for this patient.