Endo re-treatment help...

[PlaqueAttack]

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I'm currently a 3rd year and i have a pt that presented with a loose post and crown on #8. The pt is now about 40 and had an accident while in elementary requiring endo/post/core/crown. The X-rays reveal a good apical seal < 1mm from the apex and no radiolucencies, would it be advisable to only replace the post/core/crown and forget about re-treating the canal??
I talked to the endo faculty at my school and of course they wanted to re-treat but i'm kind of thinking that's like asking an Oral Surgeon if wisdom teeth should be prophylactically removed. If there were good seals at the apex and the crown/post than any residual bacteria would be entombed and would not have any nutrients etc.. right?? even if they were anarobic it wouldn't matter?? any comments or thoughts will be appreciated

 

[SuperC]

I'm currently a 3rd year and i have a pt that presented with a loose post and crown on #8. The pt is now about 40 and had an accident while in elementary requiring endo/post/core/crown. The X-rays reveal a good apical seal < 1mm from the apex and no radiolucencies, would it be advisable to only replace the post/core/crown and forget about re-treating the canal??
I talked to the endo faculty at my school and of course they wanted to re-treat but i'm kind of thinking that's like asking an Oral Surgeon if wisdom teeth should be prophylactically removed. If there were good seals at the apex and the crown/post than any residual bacteria would be entombed and would not have any nutrients etc.. right?? even if they were anarobic it wouldn't matter?? any comments or thoughts will be appreciated

You are a little farther along than me, but I don't see the point of the retreat. Your rational seems to make sense.


Here is a similar case where the Dr did not retreat.
-C

 

[NileBDS]

I'm currently a 3rd year and i have a pt that presented with a loose post and crown on #8. The pt is now about 40 and had an accident while in elementary requiring endo/post/core/crown. The X-rays reveal a good apical seal < 1mm from the apex and no radiolucencies, would it be advisable to only replace the post/core/crown and forget about re-treating the canal??
I talked to the endo faculty at my school and of course they wanted to re-treat but i'm kind of thinking that's like asking an Oral Surgeon if wisdom teeth should be prophylactically removed. If there were good seals at the apex and the crown/post than any residual bacteria would be entombed and would not have any nutrients etc.. right?? even if they were anarobic it wouldn't matter?? any comments or thoughts will be appreciated

I would re-treat, for sure. Here is my reasoning:

1. Right off the bat, we know that this particular RCT has been there (and apparently has done a great service for this patient) for 20+ years. Assuming you go ahead with your planned treatment (I'm guessing another post/core/crown), and that endo just gives up on you a couple of years down the road... Now what ? You get the picture ...

2. You do not know how long that post/core/crown has been loose. How long has this coronal leakage been going on ?

3. X-rays are not proof of a good apical seal. You can only tell so much from a radiographic interpretation. And by < 1mm, I hope you meant > 1mm (I personally would be more comfortable with at least 3-4 mm, specially that you should have a nice long wide conical root).

I could list a couple more, but these alone are pretty good arguments for a re-tx.

As a cautionary note, I would certainly want to eliminate the possibility of any vertical root fractures in this case, since you have a long standing (metal) post in a guiding tooth, and now it's loose. In such cases, always assume it is there, unless you can determine else wise. A post in a single rooted tooth, which is constantly subject to lateral forces and torquing is not the same as a post in 1 of 2 or 3 roots of a molar tooth (not to mention none to little lateral cycling).

 

[Cyclysm]

I'm currently a 3rd year and i have a pt that presented with a loose post and crown on #8. The pt is now about 40 and had an accident while in elementary requiring endo/post/core/crown. The X-rays reveal a good apical seal < 1mm from the apex and no radiolucencies, would it be advisable to only replace the post/core/crown and forget about re-treating the canal??
I talked to the endo faculty at my school and of course they wanted to re-treat but i'm kind of thinking that's like asking an Oral Surgeon if wisdom teeth should be prophylactically removed. If there were good seals at the apex and the crown/post than any residual bacteria would be entombed and would not have any nutrients etc.. right?? even if they were anarobic it wouldn't matter?? any comments or thoughts will be appreciated

i have heard of this guy in ann arbor called "the passion" and i think that you should consult him. he can only be found by those who seek him. just beware of his lady guardian because she has been known to leave her mark on those who challenge her dominance. go forth and seek the passion, he will guide you.

 

[DrJeff]

Dental school pricing might make this a little different, but in all seriousness, if your looking at a re-treat endo, new post/crown take a look at the long term success rates (and cost) of that treatment scheme vs. extraction and restoration of that tooth with an implant and crown.

 

[OceanDMD]

Dental school pricing might make this a little different, but in all seriousness, if your looking at a re-treat endo, new post/crown take a look at the long term success rates (and cost) of that treatment scheme vs. extraction and restoration of that tooth with an implant and crown.

I have to disagree with you here. The first time around the endo success rate is around 95%--similar to an implant. lets say after a retreatment it drops to 90%. This patient has no symptoms, how could you justify an extraction? In addition, lets say you fracture the alveolus, or lose a papillae through the process. No way. If its me, I want the natural tooth if at all possible. Implants are great, (I have two of them), but what nature created is always the best option if possible. Just my opinion for what its worth.

 

[DrJeff]

I have to disagree with you here. The first time around the endo success rate is around 95%--similar to an implant. lets say after a retreatment it drops to 90%. This patient has no symptoms, how could you justify an extraction? In addition, lets say you fracture the alveolus, or lose a papillae through the process. No way. If its me, I want the natural tooth if at all possible. Implants are great, (I have two of them), but what nature created is always the best option if possible. Just my opinion for what its worth.

The only thing about this case that really concerns me(and its impossible to say without x-rays) is if that existing post loosened up due to secondary caries, by the time you retreat and reprep that tooth for a new post/core, that risk of future root fracture gets a little high for my tastes when compared to an implant. Sure you've got the potential for tissue issues with the implant, but personally I'd much rather deal with that risk than a root fracture at which point you's be looking at an implant anyway as a tx option(without having incured the cost of that retreat/new post+core and crown).

I'm also a bit biased towards this since the endodontist that I use for just about all of the re-treats charges essentially the same for a retreat that the oral surgeon who places most of my implants does for implant placement.

This is a really good topic for debate, and just makes an excellent learning point that there's very often more than one viable treatment option for every situation.👍

 

[dentalmental]

If it was not secondary caries that lead to the failure of post/core/crown, and if the patient turned up immediately after the failure, I feel there wouldn't be a need to re-treat considering the situation mentioned by the OP. Why wake up a slumbering giant?

Just my 2 cents..

 

[PlaqueAttack]

thanks for all the replies and opinions, there were no secondary caries when the pt initially presented and I did mean > 1mm, and this "Passion" that you speak of will definitely be consulted Cyclism. We did mention implants to the patient but she did not want to go months w/o a central and the faculty I was working with thought immediate loading would be out of the question in this case...but I could send it to grad perio/prosth and see if they would possibly do it

 

[charlestweed]

extraction and restoration of that tooth with an implant and crown.

This is a very good alternative treatment option. If the patient is concerned about not having a tooth there during the implant integration phase, the surgeon who places implant can also place an additional IPI implant (Immediate Provisional Implant) to hold #8 provisional crown.

 

[Elipar]

I believe the rationale for re-do has to do with the loose post. Since you didn't have an effective coronal seal, you KNOW that thing has been leaking. So... do you really want to go cementing a new post just to have the thing explode??? If it wasn't going to receive a new post, I'd be more apt to prep a new crown. But since it's going to get a post and be significantly harder to re-treat should problems arise, I'd just do the RCT first.

 

[ktcook83]

thanks for all the replies and opinions, there were no secondary caries when the pt initially presented and I did mean > 1mm, and this "Passion" that you speak of will definitely be consulted Cyclism. We did mention implants to the patient but she did not want to go months w/o a central and the faculty I was working with thought immediate loading would be out of the question in this case...but I could send it to grad perio/prosth and see if they would possibly do it

Passion here chiming in... lol.... FWIW, I had a patient with a very similar situation. Tooth #9 w/ P/C/C became loose. After evaluation with the attending faculty, it was decided that the prep sucked and had next to zero ferrule effect. It had been recemented 2 other times by previous students w/ Fuji Plus. We decided to use a resin cement this time... Panavia 21, I believe. We sandblasted and treated the restoration and recemented it. After, we took the tooth slightly out of occlusion, knowing the tooth would eventually hypererupt back into anterior guidance. All of this was explained to the patient before recementation and he was given the option of a re-tx of the endo or an implant. At the present time, he wanted to recement it and take his chances, planning to do an implant if and when it failed. We gave him the "parking lot" guarantee. That was 4 months ago and I haven't heard from him since.

W/R/T your pt, if you go the implant route... which is what I would push... check her smile line... see if the soft tissue is even something to really be worried about. Even if it is, I'd take my chances as Dr. Jeff said. Also, since she doesn't want an edentulous space there, toss a flipper in there until the implant is ready for restoration.

 

[Cyclysm]

check her smile line... see if the soft tissue is even something to really be worried about.

you speak as if you have had a lecture on this recently...

 

[doc toothache]

I'm currently a 3rd year and i have a pt that presented with a loose post and crown on #8. The pt is now about 40 and had an accident while in elementary requiring endo/post/core/crown. The X-rays reveal a good apical seal < 1mm from the apex and no radiolucencies, would it be advisable to only replace the post/core/crown and forget about re-treating the canal??
I talked to the endo faculty at my school and of course they wanted to re-treat but i'm kind of thinking that's like asking an Oral Surgeon if wisdom teeth should be prophylactically removed. If there were good seals at the apex and the crown/post than any residual bacteria would be entombed and would not have any nutrients etc.. right?? even if they were anarobic it wouldn't matter?? any comments or thoughts will be appreciated

Thirty years of service from a p/c/c/ is impressive. The more critical question is whether or not there were contributing factors for the failure. Was there any fracture of the incisal portion of the tooth, recurrent decay, etc.? Failure of p/c/c/ are usually due to an inadequate amount of tooth structure left (prep/crown ratio) and over tapering of the prep. A cast post would be preferred over a pre fab since the former will give better adaptation and allow less lateral movement of the (cast) post. Re treatment would be ideal, although cost may be an issue. Endo failure at a later date will need to be addressed with apico/retro. There is not a cement available (including Panavia 21) that will make up for failure to take into account the mechanical forces acting on the p/c.

 

[RubberBase]

What I love most about dentistry, and the least about dental school, is the multiple Tx plans that would potentially work. The real factor is the amount of healthy tooth structure remaining. If there are 3+ mm of uninterrupted seal, no internal resorption and at least 270 degrees of ferrule available (particularly B and L as opposed to M and D), then just redo the p&c and crown. In this day and age, if any of those requirements are not fulfilled, yank it an' crank it. A well made flipper, or even a Maryland bridge, with an ovate-pontic-ish tooth should satisfy the patients esthetic needs and even help shape the papilla post-implant surgery. Drop a Captek crown on the implant and you're in business.