placing amalgam in an existing amalgam restoration...

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Dental916

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I've heard that you should not place amalgam in an existing amalgam restoration, but lets say the patient has a MO with a mesial lingual cusp built up from amagam on tooth 19. The pt has recurrent decay on the occlusal, but the margins/seal of the built cusp look perfect. Is it ok to chase the recurrent decay(say it doesn't extend too far)and place amalgam and burnish really well with existing amalgam? If you remove say the whole amalgam restoration, you can possibly cause pulp damage, not get great seals etc. so I am up in the air about this. I haven't really asked my faculty about it...I was just thinking. I guess the best answer would be from them.

Another option would be to place a composite...which I thought is ok to do...right?

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I've heard that you should not place amalgam in an existing amalgam restoration, but lets say the patient has a MO with a mesial lingual cusp built up from amagam on tooth 19. The pt has recurrent decay on the occlusal, but the margins/seal of the built cusp look perfect. Is it ok to chase the recurrent decay(say it doesn't extend too far)and place amalgam and burnish really well with existing amalgam? If you remove say the whole amalgam restoration, you can possibly cause pulp damage, not get great seals etc. so I am up in the air about this. I haven't really asked my faculty about it...I was just thinking. I guess the best answer would be from them.

Another option would be to place a composite...which I thought is ok to do...right?

Dental school is all about what the faculty want. If you want to try it when you get out on your own, by all means go for it. But for now, just find out what they want and do exactly that. It'll make life so much easier.
 
I've heard that you should not place amalgam in an existing amalgam restoration, but lets say the patient has a MO with a mesial lingual cusp built up from amagam on tooth 19. The pt has recurrent decay on the occlusal, but the margins/seal of the built cusp look perfect. Is it ok to chase the recurrent decay(say it doesn't extend too far)and place amalgam and burnish really well with existing amalgam? If you remove say the whole amalgam restoration, you can possibly cause pulp damage, not get great seals etc. so I am up in the air about this. I haven't really asked my faculty about it...I was just thinking. I guess the best answer would be from them.

Another option would be to place a composite...which I thought is ok to do...right?

The temptation to do patchwork dentistry may be even more acute when dealing with a tooth that has had 2 or more cusps with pin supported amalgam. Applying a band aid solution may be a disservice to the patient since there may a higher probability of failure of the remaining restoration. The concern for additional pulpal damage may not be warranted, unless we are worried about an iatrogenic result.
 
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In the real world, you have to assess the situation and determine if it's worthwhile to replace the entire filling or not. Sometimes if it's a small patch and doesn't reduce the old filling's resistance and retention form too much then you can try the repair with either amalgam or composite.

A small opening can lead to an extensive amount of decay underneath, and after caries removal it can turn out that it's best to remove the old filling and place an entirely new one. I usually warn the patient that if the cavity is really bad, we may as well just put a whole new one in.

But for example say there is a huge honking MODBL with pins on a tooth, and there is only a slight bit of decay right at the buccal margin. The patient wants to hold off on a crown, and perhaps has limited funds. Do you insist on replacing the entire filling or just do some patch work instead? Personally I have no problem with placing a small repair as long as it will help the situation.
 
I'm against repairs. If I'm going to work on a tooth, I'm going to certify that the tooth is in good condition. That means if there's an old filling, it's coming out. What if it's got pins and cusp replacements and... it is what it is. If it's THAT big, it's going to get a crown. Patient finances and desires may say otherwise, but that's for another dentist to decide. Do what you feel comfortable doing and have reasons to back it up.
 
I'm against repairs. If I'm going to work on a tooth, I'm going to certify that the tooth is in good condition. That means if there's an old filling, it's coming out. What if it's got pins and cusp replacements and... it is what it is. If it's THAT big, it's going to get a crown. Patient finances and desires may say otherwise, but that's for another dentist to decide. Do what you feel comfortable doing and have reasons to back it up.

I fully agree. In my opinion, the entire restoration has to come out, especially if another dentist placed it. I don't know what's under it, I don't know the quality of work they do. Once I place a restoration there it becomes my problem, so why would I allow another dentist's work to become my problem?
 
That's easy enough to say, but I wouldn't make it a general rule too quickly especially with larger fillings that just need a small repair. We evaluate restorations every day to determine whether they need replacement or not so I don't consider this that much different.

I personally would weigh the risks and benefits of each case and carefully consider the potential of iatrogenically creating an irreversible pulpitis when it could have been avoided. Consider the consequences of making a problem when there wasn't one to begin with. I would much rather inherit someone else's problem than create my own.

Here's a scenario for you. Patient comes in, notices just a small cavity at the buccal margin of a large filling. Tooth has never bothered him for 15 years. You check out the filling, and all margins except that buccal are intact. No radiolucencies on the xray. You say, let's replace the whole thing because I don't know what's under it. I don't want to inherit some other dentist's problem. Patient trusts you and says okay. After placing the new filling, the patient has a severe lingering ache and requires a root canal due to removing and replacing the large filling that was very close to the nerve.

Imagine a similar scenario : you or your mom or litigation lawyer has an old deep amalgam filling that looks like it is sitting 0.5 mm above a pulp horn with no symptoms, xray findings or pathology present for the last 15 years. It has a small marginal defect which is decaying but otherwise is fine. Would you ask the dentist to replace the entire filling when he tells you that he thinks that a repair would take care of it?

If you're comfortable in dealing with the consequences and have thought over your choices carefully that's fine, continue with your preferences. To each their own as they say. If you are just following something that some other dentist has told you in passing during a clinic or somewhere, I suggest that you think over the pros and cons of that advice.
 
I think Gavin and ZZZZ are both right. You are taking responsibility for every filling you do, and you need to do what is best for both you and your patient. There are a ton of factors that go into deciding when to replace an old restoration and when to just "patch" it. Make sure you weigh the good and the bad of both, and make sure the patient completely UNDERSTANDS what you two have decided, so when the old/new restoration fails, the patient isn't surprised and doesn't go to another doc and bad mouth you to the new doc and every person they know.
 
That's easy enough to say, but I wouldn't make it a general rule too quickly especially with larger fillings that just need a small repair. We evaluate restorations every day to determine whether they need replacement or not so I don't consider this that much different.

I personally would weigh the risks and benefits of each case and carefully consider the potential of iatrogenically creating an irreversible pulpitis when it could have been avoided. Consider the consequences of making a problem when there wasn't one to begin with. I would much rather inherit someone else's problem than create my own.

Here's a scenario for you. Patient comes in, notices just a small cavity at the buccal margin of a large filling. Tooth has never bothered him for 15 years. You check out the filling, and all margins except that buccal are intact. No radiolucencies on the xray. You say, let's replace the whole thing because I don't know what's under it. I don't want to inherit some other dentist's problem. Patient trusts you and says okay. After placing the new filling, the patient has a severe lingering ache and requires a root canal due to removing and replacing the large filling that was very close to the nerve.

Imagine a similar scenario : you or your mom or litigation lawyer has an old deep amalgam filling that looks like it is sitting 0.5 mm above a pulp horn with no symptoms, xray findings or pathology present for the last 15 years. It has a small marginal defect which is decaying but otherwise is fine. Would you ask the dentist to replace the entire filling when he tells you that he thinks that a repair would take care of it?

If you're comfortable in dealing with the consequences and have thought over your choices carefully that's fine, continue with your preferences. To each their own as they say. If you are just following something that some other dentist has told you in passing during a clinic or somewhere, I suggest that you think over the pros and cons of that advice.

There are no guarantees that even a conservative amalgam (patch) on any surface of the tooth will not trigger an endo mode.
 
There are certainly no guarantees, and I don't think we're talking about offering guarantees in this thread. In dentistry I think that we tend to work based on probabilities. For example, I would bet a small patch would cause a problem a smaller percentage of the time than a complete replacement of a large filling.

I also would bet that a small stitch on a finger would likely cause a problem a smaller percentage of the time than complete finger reattachment surgery. That's not to say that there's no chance of complications in having a stitch placed or guaranteeing that no problems will occur.

Patients will bad mouth you no matter what you do. That's a fact of life. I had one mom get mad at me because we wanted to postpone a sealant appointment after her child almost threw up because he was a severe gagger. She promptly saw the other dentist who forced the child to sit through the appointment, and judging by all the wretching and squirming, I'd be surprised if those sealants stayed on for longer than a week. In those cases, you just gotta say "Whatever." 🙄 I just do what I think is right, and really you don't want to be everyone's dentist or try to make everyone happy.

I suppose we could argue about this forever on the internet, and you know how productive that really is. People are going to do whatever they want to do in the end. I'm just suggesting that it's nice to rethink some protocols, consider the reasoning behind them and weigh the risks and benefits as well as probabilities of certain outcomes in performing that treatment.
 
i see both sides, but at the end of the day, i wouldnt want to take responsibility for someone else's work. and i've been told that standard of care is to remove all old restorations.
 
We learned that patching amalgam will lead to a flexure strength of less than 50% of the amalgam that is repaired. This procedure is basically considered hazardous and is only indicated in areas that are not going to be subjected to high stresses. The previous corrosion products will likely interfere with any new bonding. It sounds like a bad option.
 
I think you do have to keep in mind that those studies are comparing baseline flexural strength with that of the joined amalgam pieces. In a small area of repair that is enclosed between solid tooth structure and solid amalgam, I don't think bond flexural strengths really come that much into play. But if someone is trying to repair half a sheared off amalgam cusp, for example, then sure they will likely run into problems with flexural and bond strength.

You really have to judge the situation if you're going to attempt a repair. Half the time the decay has advanced under the amalgam so much that it's not indicated. The other time it's a small amount of decay that doesn't compromise the strength of the remaining filling and doesn't extend very far in so I don't have a problem trying to pop a small repair in there.

Like I mentioned, you really have to weigh the risk and benefits of any procedure with the patient. Assess the situation and make an educated judgement call as a clinician.
 
Like I mentioned, you really have to weigh the risk and benefits of any procedure with the patient. Assess the situation and make a educated judgement call as a clinician.

Bingo! Just because your profs teach you a specific thing in d-school, doesn't necessarily mean its the only way that it can be done. Probably the biggest thing you gain with time in private practice isn't speed, but clinical experience where you're able to asses each situation based on what you've seen work/fail not over a matter of months, but years and even decades. I still today both love and hate when I have a patient come in with a non carious failure of a restoration I placed. I hate it because I have to redo it, but I love it because it gives me the opportunity to asses why the 1st restoration I placed failed and what I can do to fix it to prevent future failure (sometimes this will mean altering my prep, sometime altering restorative material and sometimes the type of restoration).
 
Bingo! Just because your profs teach you a specific thing in d-school, doesn't necessarily mean its the only way that it can be done.

I agree. I just want to make sure that I don't ever do my patients a disservice by cutting corners if there is a better way that is a viable treatment option.
 
Really dentistry isnt black and white. That is why you are a doctor you have to think and assess each clinical problem that is placed before you. I wouldnt repair a MODL with pins the tooth should be crowned. So really if its a small amalgam say a occlusal then why not replace it. If its a enormous amalgam why would any clinician recommend repairing it. Do the patient a favor and give them something that will last and wont require patch up dentistry for the rest of the life of the tooth. If lets say that the patient was adamant about not getting the crown on a MODL with pins. There was only a small defect. The patient has no chief complaint then what minimally invasive dentist wouldnt 1st try to just patch it. The chances of patient developing pulpitis are much lower than taking out an enormous amalgam on a asymptomatic tooth. But you are the doctor. If I was in the chair I would hope my dentist would weigh all things and make a decision that he felt was in my best interest and not just follow protocol A=B etc.
 
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