RCT vs Extraction?

This patient presented with a buccal parulis by #30. The periapical radiograph showed an obvious radiolucent lesion surrounding most of the mesial root and furcation. Her dentist recommended endo retreatment. I disagreed and did not think the prognosis of the tooth was favorable due to the anatomy of the radiolucent lesion. Nevertheless, she desperately wanted to keep the tooth since she did NOT like the thought of extraction and implant replacement. How do you interpret this scenario and what would you recommend for this patient?

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I agree with you that this might not be the best option though I would encourage the patient to go forward with the endo. The nice thing about our profession is that everything we do is elective and at the end of the day it is just a darn tooth. I think there is a real possibility that there is a strip perf along the mesial root but after re-treatment this could be dormant for a number of years and the patient can then have his/her wish of maintaining this tooth in a comfortable manner for the immediate future. Luckily this should make an ideal situation to place an immediate implant in the future if and/or when that day comes. I am not sure how the endo guys in your neck of the woods operate but here the ones that I usually work with would probably opt to refer this patient for extraction/implant as they are not too greedy and seem to do the right thing…

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Hi, thanks for sharing the case.
If you consider the endodontic treatment done at the best and no further may be achieved, you may have two options:

  1. Extract and restore (implant, tooth-supported…).
  2. If you diagnose a through and through furcation defect, then hemisection may be considerable as distal root may be preferred to retain, followed by a narrowed-occlusion table crown. Bicuspidization or tunneling does not seem favorable due to the bone loss/remaining bone level at the mesial root. But, as a single radiography may lead to misinterpretation, you may also be diagnosing a CII furcation defect with a deep vertical (pocket) component which may call for a regenerative periodontal approach.
    Periodontal probing will help for definitive diagnosis and proper treatment plan. Demonstrating the probing sequence to the patient by an intraoral cam or scanner may be a good idea for informing the patient, as it is not always so comprehendable for the patient to understand periodontal aspects only thru oral presentation.
    Hope that helps.

I have seen many cases like this in 37 years of practice. Almost none responded 100 percent to retreatment and when I finally took the molar out, the exterior root surface was black. It feels like I’m seeing more of these types of lesions in cases where the “crown down” machining is leaving much less dentin at the furca. It’s possible our endo is iatrogenically causing eventual failure.

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So you retreat and close with a build up. The patient spends thousands of dollars and 2 years later the root fractures and needs extraction? In my 37 years of practice, I have always tried to do what I would want done in my own mouth. I personally feel retreating this is a disservice to the patient, not to mention the $$ lost. Just my opinion.

Trying and paying for reTreatment probably only will postpone the outcome : remove and decide. If this was my mouth I wouldn’t hesitate to remove (qualified in 1981and have not seen 1 case that presents similarly succeed “longterm”) It may be a “darn tooth”, sure, yet I’d still try and influence the choice of treatment leaving the final decision to the patient.

The previous endo is not good, with a lot of ultrasonic irrigation and MTA should be able to save the tooth

there is a significant periodontal lesion there, that RCT alone would not treat

“Her dentist recommended endo retreatment”
“she desperately wanted to keep the tooth since she did NOT like the thought of extraction and implant replacement”

These are both quotes taken directly from the authors original post which are important factors in how I would advise this patient to proceed. While I no doubt have a personal bias toward replacing this particular tooth in its current condition with an implant I do not claim to be of the caliber of beings that can predict the future. I would be very interested to see how “experts” on an endo forum would predict the outcome of this case…

This is a scenario we see fairly regularly. Most patients such as this who may have had the endo treatment recently understandably prefer to save the tooth in preference to the extraction/implant route. The lesion seen is within the furcation region and is almost surely related to a perforation on the distal surface of the mesial root. It is not from the apex or related to a “short fill” which may improve with a retreatment. Retreatment of this tooth is very likely a waste of time and money and would only serve to delay the inevitable needed extraction. I will always discuss the option of retreatment vs extraction and give projections of result. Almost all patients understand this and opt for the most predictable long term outcome which is to punt and replace.

Definitely extraction. The surgical view of the lesion will ALWAYS be much larger than the radiological one. Do not endanger the vestibular wall. Suerte !

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That is certainly my experience and bias but the ultimate decision maker in this case, the patient, has a strong desire to keep the tooth. If a trained endodontist feels it is worth retreating than it is certainly worth it and to be honest none of us have any idea exactly how long the treatment will last. Isn’t every dental restoration rather an endo tooth or an implant just a dormant problem??? The best dentistry in the world is nothing more than man’s imperfect attempt to recreate a once perfect situation

I agree. Practiced 41 yrs and I don’t get heroic on endo any longer. Statistically your success with an extraction ,graft and Implant placement would work out better, and cut the losses($$), with failing endo.

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No obvious radioluscency periapically - it points to towards root fracture/perforation or periodontal problem.

I get a fair bit of questions, as I am sure you all do: “should I have this endo retreated?”. My answer is-ask the endodontist what % likelihood is a 10-year outlook? if you like the answer, go for it. I am not the expert in endo prognosis. Most of my referring Drs would have that tooth removed.

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