June 2021 – How far does the referral go? Tx Planning for Optimal Patient results?

How far does the responsibilty of the Endodontist extend?

A 58 year old female patient has been referred because a draining Bu sinus was noted during her hygiene appointment. The patient was symptomatic but the RD wants to replace the 3 unit bridge #25-27 due to mesial decay under the crown  margin of the distal abutment #27 and poor crown margins in #25.  Persistent radiolucent findings were noted at the apex of #27 and were likely associated with the draining buccal sinus. Perio probings were WNL.

The patient has also recently had #36 temporized with a temporary crown. The original core restoration appears close to the D pulp.  #37 appears to have mesial marginal caries and a poorly made crown with poor contours and overhung margins.  The patient had the work done in Eastern Europe 12 years ago and is happy with the aesthetics.

So, what is the responsibility of the Endodontist in this case?  Do were merely treat #27 with no regard to the other restorative issues present that have potential to compromise the endodontic treatment, should they not be addressed?

What factors need to be considered?
1. The need for a new bridge and endo retreatment of #27 ? OR do we just go through the crown and NOT worry about the crown margins?

2. Are we concerned about the condition of opposing #37? Will the patient’s budget allow for replacement of the  crown or should it be extracted? Will the patient’s budget allow for Endo treatment of #37 if it is necessary?  60-70% function of #27 D bridge abutment will be lost if we extract #37.

3. Possible need for Elective Endo on #36 prior to new crown restoration due to lack of core, pulp calcification/exposure or proximity to pulp? Again, will the patient have to choose between #36 and/or #37 or Both?  Financial considerations? When are these discussions to be had? AFTER referral?


The patient also had a draining buccal sinus in the right posterior maxilla that was previously addressed by me with with Endo treatment of the D abutment #17. (Post space requested postop). The bridge in this area may also may need to be redone due to the poor D crown margin. There also is an open contact between #18 and 17 and gross marginal decay under the crown of #18. (repaired with amalgam?) Do we Endo treat #18  as well and re-restore it or extract it?

WHO decides…and  WHEN?

Are we merely treating to the symptoms: Pain and obvious swelling/draining sinus? Or is there a plan for the mouth that is not merely “putting out fires”? Successful endodontics is only as good as the restorative treatment plan that follows it.